Social Work: Value-Guided Practice for a Global Society [Pilot project. eBook available to selected US libraries only] 9780231536882

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SOCIAL WORK

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SOCIAL WORK Value-Guided Practice for a Global Society

CYNTHIA BISMAN

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 Bisman, Cynthia. Social work : value-guided practice for a global society / Cynthia Bisman. pages cm Includes bibliographical references and index. ISBN 978-0-231-15982-1 (cloth : alk. paper) — ISBN 978-0-231-53688-2 (e-book) 1. Social service. 2. Social service—Practice. I. Title. HV40.B5433 2014 361.3'2—dc23 2014013019

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: Adam Bohannon 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.

Y CONTENTS

Acknowledgments

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1. Value-Guided Practice for a Global Society: An Introduction

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2. Organizing the Ideas of Social Work

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3. Ethical Practice Toward Social Justice and Human Well-Being: Local and Global

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4. Evidence for Knowledge-Guided Assessments

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5. Respect and Dignity in Relationships

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6. Interaction and Meaning in Communication

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7. Critical Consciousness for Differential Use of Self

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8. Evidence and Best Practices for Strategic Interventions

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References Index

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Y ACKNOWLEDGMENTS

During the spring of 1999 I was a visiting fellow at the International Social Sciences Institute, University of Edinburgh, Scotland.Years later I was a visiting professor and resident fellow in St Cuthbert’s Society, at the University of Durham, England. These sabbaticals provided particularly rich occasions for venturing into new research exploring the profession’s heritage in values and ethics. Access to original historical documents was buttressed by discussions about social work and social welfare, with British social workers and educators, and also with scholars from other disciplines and professional occupations. I specifically acknowledge Sarah Banks, Eric Blyth, Chris Clark, Derek Clifford, Vivienne Cree, and Michael Preston-Shoot for embracing me and my work in sharing their rich and varied perspectives. On a more recent sabbatical I was able to meet with academic colleagues in Greece and Italy and was offered exceptional support by Eleni Papouli, Annamaria Campanini, Cristina Tilli, and Michelle Ciarpi. They all enriched my understanding about social work practice from a global perspective. For these and so many opportunities I will be eternally grateful to Bryn Mawr College (BMC). As provost and now as president, Kimberly Cassidy has been supportive of my research. Her encouragement of colleagueship across disciplines enabled close and productive relationships in which I could expand on the scholarship begun in the sabbaticals. I especially thank my BMC colleagues Michael Allen, Grace Armstrong, Christine Koggel, and Mary Osirim for their ideas and analyses about international perspectives, reinforcing the importance of multidisciplinary collaboration in our global society. I also acknowledge two Graduate School of Social Work and Social vii

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Research (GSSWSR) research assistants, Lisa Couser and John Edwards, who helped with literature searches. Notwithstanding continued technological developments, taking on the role of social worker involves integrating skills with multiple bodies of knowledge. In their mission to create both individual and social change, social workers continually struggle with effects of meaning and process, while balancing often conflicting ethics and mores, made ever more challenging by globalization. It is my hope that this book’s emphasis on values enriches knowledge and improves practice through its re-envisioning of social work and the social welfare in a global society. The narratives and case studies are from the many front-line practitioners in a range of locations who so generously gave of their time. I thank them all and wish I could publicly name them individually. Reflected in these pages is important work by U.S. colleagues including Elaine Congress, Bart Grossman, Lynne Healy, Carmen

Hendricks, Kathy Pottick, Robin Mama, and Frederic Reamer. I expressly thank my Foundation Practice students of nearly 40 years for stimulating me to develop this book. Jennifer Perillo has been an extraordinary editor. She believed in this project and along with her assistant, Stephen Wesley, was always available to help with deadlines and offer wise guidance. I thank them both that we are finally at this stage. The brilliance of my son, Graham Brownstein, has always been an inspiration. I thank him and his father, Donald Brownstein, for their valuable insights. My husband, David Hardcastle, Professor Emeritus, University of Maryland School of Social Work, patiently helped me stay focused on social work’s breadth. He has been a source of infinite support and encouragement, sharing his vast wisdom and intellectual acuity about this profession we both dearly love. I am forever grateful for his enduring friendship, kindness, and guidance.

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1 Value-Guided Practice for a Global Society An Introduction

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What happens here in the United States affects my family in Mexico and the worth of the euro, and what happens in Africa affects my friends in the United States; we don’t realize how we are all connected. I chose social work to make the world a better place. —A social worker

his book has been written to extend generalist practice in ways essential to 21st-century demands. It provides readers a comprehensive text that covers the values, knowledge, and skills necessary for all social work practitioners. New definitions and explanations for the established tenets of social work concepts and principles including assessments, relationships, communication, differential use of self, best practices, and interventions are illustrated and integrated with case material for practice guided by the profession’s values and ethics. Recognizing that practice with individuals is the shared foundational skill of every social worker, this comprehensive text is unique among the many on the market in covering what all students need to know for ethical practice with individuals in a world changed by globalization.

I was adopted as a Vietnamese orphan before I was 1 year old. Raised in New York City and licensed to practice social work there, I have never been to Asia. Now I am seeking to adopt a 2-year-old girl whose mother’s custody has been terminated. Adoption social workers only want to focus on how my Asian heritage will affect my ability to parent. this child, whose birth family came to the United States from Guatemala. I found this frustrating. There were many areas of concern for me, such as the child’s abuse and trauma; ethnic background was not one of them. Shouldn’t we focus practice on “where the client is”? —A social worker

Global Consciousness This book explores the topic of global consciousness, introduced as a new construct for the social work  profession. The global interconnectedness that increasingly defines the early 21st century has shifted populations and economic structures, requiring innovative ways to think about and implement the welfare state; this demands novel approaches from the social work profession. Toward this end, global consciousness provides an original framework for practice across systems and across ethnic backgrounds and national borders.

Never believe that a few caring people can’t change the world. For, indeed, that’s all who ever have. —Margaret Mead, feminist, humanist, cultural anthropologist How could you get back what has disappeared? —Kiki Dimoula, national poet of Greece The world we have created is a process of our thinking. It cannot be changed without changing our thinking —Albert Einstein

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Global consciousness prepares social workers for contemporary practice. Extending the important and necessary framework of international social work from its underpinning in nation-states, global consciousness provides a construction to understand a world in which circumscribed national boundaries no longer suggest reasonable assumptions about culture, ethnicity, language, and norms of behavior. Global consciousness allows for practice through a continuous global perspective, regardless of the initial geographic origin or current location of clients and practitioners. Important contributions of international social work over its long history include recognition of and advocacy for action around international issues concerning domestic practices and policies, troubles shared by nations, dilemmas emerging from large-scale displacements and migrations, and international exchanges. These activities remain relevant and necessary. Global consciousness specifically targets a changed world with boundaries obscured by globalization and technological developments. It considers social work within a context of rapidly changing populations and communities that are now simultaneously local, global, and virtual. Social work practice with a global consciousness incorporates the lens of both geographic and cultural context, drawing from the profession’s values and skills as well as from multidisciplinary knowledge and skills to respect the uniqueness of each person and situation and also to recognize the universality of shared experiences. In these chapters, global consciousness provides a new paradigm for social work by viewing the global in the local. The National Association of Social Workers (NASW) ethical Standard 6.01 states: “Social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments” (National Association of Social Workers [NASW], 2008 [1996], p. 21). Accreditation guidelines set by the Council on Social Work

Education (CSWE) now require international content in the curriculum of U.S. social work programs (Council on Social Work Education, 2008).The term global consciousness has a number of meanings and practices in a range of fields. At Princeton University, global consciousness is a multidisciplinary virtual project that explores linkages between people and the earth while attending to issues of presence and activity of consciousness. The Center for Consciousness Studies in Tucson, Arizona, attends to parapsychology phenomena. Jeremy Rifkin, an economist and international affairs expert, has written numerous books on climate and the environment, offering a reinterpretation of history from an empathic lens of expanded human consciousness. He believes that as technological developments open people up to a wider world, they may also help to create a more caring world: “New developments in global Internet connections suggest that it might be possible to imagine a paradigmatic shift in human thought and a tipping point into global consciousness” (Rifkin, 2009, p. 472). Suárez-Orozco and colleagues’ (2007) approach to this term is closest to the one developed and illustrated in this book with its emphasis on learning and understanding in the global era. This book develops and uses the following definition of global consciousness for social work: Global consciousness is a recognition of the world as a unity consisting of complex interactions among people across the globe. In viewing the world as one ecological system, global consciousness requires critical thinking and communication that is open and sensitive to multiple meanings for the same phenomena.

For practice with a global consciousness, social workers must be able to 1. Attend to a global society with its complex mixture of people and environments. Social work’s person-in-environment perspective must be broadened across ethnic, racial,

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cultural, and geographic variables, incorporating the profession’s mission of human well-being, which includes both individual and social well-being. Respect the uniqueness and dignity of all people and advocate for their empowerment. Through human relationships, social workers advocate for and with clients to foster self-determination and empowerment and to create change in a range of individual and social conditions. Remain aware of self as simultaneously distinct from and in community with others. This requires reflexivity—looking outside of oneself from the perspective of another person while at the same time recognizing one’s worldview and membership in particular groups. Convey curiosity and caring through differential use of self. This demands articulation of one’s biases and personal reactions to client situations, accompanied by flexibility and openness in reaching out to a diverse world. Embrace critical thinking and critical practice. These are skills of reflection and action in using reasoning, geographic and cultural context, peer-reviewed scholarship, and the profession’s values and skills while also recognizing the client system as the best ethnospecific cultural expert. Promote communication within and across borders with sensitivity and tolerance for multiple meanings attributed to the same phenomena. Recognition of and respect for differences in languages and cultures and the infinite ways of interpreting events are necessary for one’s own communications as well as for facilitating interactions among and within cultural groups and nation-states.

Global consciousness is an important new construct for social work practice. It provides an extension to international social work made necessary by globalization. Expanding

the profession’s reach beyond culture, individuals, and their immediate communities, it encompasses the wider world as community. This recognizes the social world as one ecological system with multiple subsystems that are in continuous interaction, resulting in changes of culture, places, and people that may make them unrecognizable, as the Greek poet Dimoula so compellingly states in the epigraph given on the chapter-opening page. In its respect for the uniqueness and dignity of each person, global consciousness addresses issues of diversity and difference with sensitivity to a range of border crossings, such as class, race, ethnicity, and nationality. Whether in Philadelphia, London, or Nairobi, the movement of people requires a change in social workers’ ideas and perceptions, not a change in the physical locale of the social worker. The world comes to each location. Contexts of geography as well as of culture are therefore necessary components of practice in a global world; this new construct of global consciousness for social work practice promotes ethical practice on a global scale both within and across national borders. Values, Ethics, and a Social Morality Perspective Inherent in global consciousness is a moral perspective. Social work’s values and ethics are the profession’s distinguishing features; they provide the language for promoting the profession’s mission of social justice and human well-being locally and globally. This book translates these abstract concepts into practice to change the behavior of individuals and society—the nexus of the profession’s domain. Human rights, cultural relativism, and philosophical frameworks drawn from Appiah (2005), Kant (1785), Mill (1863 [1957]), Sen (2009), and feminist ethics of care (Koggel, 2007; Kabeer, 2012; Tronto, 2012) are examined for ethical practice in a global society. Work by various social work scholars to clarify the profession’s mission and translate the values into practice behaviors includes Dolgoff,

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Loewenberg, and Harrington (2005), Reamer (2002), and Reisch (2002). The focus in chapter 3 is on the profession’s mission to advance social morality—to embrace the dual areas of individual and social well-being that together constitute human well-being; this directly reflects the personin-environment paradigm. These perspectives inform and guide social work’s knowledge and skills, leading to the promotion of social justice. A term difficult to define, social justice means fairness and access to opportunities for social mobility and improved potential for individuals and society—a better life for all people. It requires tolerance for diversity and a broad and inclusive focus on the morality of social structures and policies as they influence both the social life and the private lives of individuals. A range of ethical codes allows examination of social work’s historical basis in morality within the context of its status as a profession. I focus on the direct linkages between its mission and the values of service, human dignity, relationships, integrity, and competence, as well as on the inherent contradictions between the ethical principles that both emerge from the values and extend them. My discussion of ethical reasoning incorporates empowerment and advocacy, and my examination of challenges and future directions discusses multidisciplinary social welfare perspectives for practice toward global social justice and human well-being. Chapter 3 also considers the conundrum faced by the profession and especially those in practice. The profession’s social justice mission reflects a universalist or deontological view— based as it is on principles of what is right or wrong and what Reamer (2012) calls “dutybased ethics,” associated with Kantian ethics and the moral philosophy adapted by Rawls (1971) for social work. Yet social work’s strong ethical commitment to cultural sensitivity and respect for difference can lean toward a consequentialist or teleological view based on what is most beneficial for the greatest number of people, a view associated with Mill (1863 [1957]).

Virtue-based ethics focuses on character and relationship—what kind of person I want to be and what I owe to others—associated with Aristotle, Confucius, Buddhism, and some religions and has received much contemporary attention for its complementing both the universalist and consequentialist views while adding the “common good” to what is “good for the individual.” Moreover, its concern with fairness can resonate with a broad range of norms in various parts of the world. Narrative- and case-based ethics also fits comfortably in this body of thinking with its emphasis on rich descriptions by clients of their stories followed by similarly rich explanations by social workers in the case studies. This book explores these challenges through case studies and analyses of practice behaviors and decision making. Banks (2006), Clifford and Burke (2009, Hugman (2005), and Butcher, Banks, Henderson, Robertson (2007) contribute perspectives critical for ethical practice. Additional Unique Features In addition to covering global consciousness and a values/ethics perspective, this book uses a historical context to frame the profession’s evolving knowledge base, mission, values, and practice components. History grounds those entering the profession so that they can draw from the past to shape new directions responsibly and evaluate emerging concepts. Contemporary relevance and effectiveness of the profession requires familiarity with the ideas and intentions of those who have come before. Chapter 2 explains and illustrates the two core paradigms of social work. “Person in environment” encompasses the multiple levels of practice—people, policies, communities, and organizations—delivered through interactions with individuals, groups, and families. “Biopsychosocial” practice includes physiologic factors (chemistry, neurology, genetics, physiology), the psychological (cognitive, affective, and emotional functioning), and a special focus on the social (community resources, social supports, income, education,

VALUE-GUIDED PRACTICE FOR A GLOBAL SOCIETY

and housing). A historical perspective introduces social work as a profession within the broad context of professional occupations and connects the founding of social work with its contemporary paradigms. This connection to history can facilitate incorporating the new construct of global consciousness with its broadening of social work’s domain to include the biosphere, organisms, and cells along with the earlier concepts of society and culture (Engel, 2003), A framework that covers history in the context of emerging ideas allows for focus on practice that addresses specific variables such as individual predispositions, familial effects on personality, social norms, and access to resources, as well as their interactive effects on each other. Chapter 4 covers case theories for assessment that incorporate evidence from multiple sources, including clients and the professional literature gathered by social workers to make sense of each client’s situation from a biopsychosocial perspective. These assessment methods organize the practice, shaping relationships, communication, differential use of self, and intervention. This chapter also addresses the complex ethical challenges for assessments within a globalized society, including technological developments and multidisciplinary perspectives. Building human dignity and respect in relationships with renewed emphasis on their core significance to the profession in fostering inclusion, belonging, and caring among people within and across national borders is the focus in chapter 5. Informed by the values of human dignity and respect and their continuing historical significance, explanations and illustrations of relationship building emphasize belief bonding along with ethical and cross-cultural challenges, purposefulness, boundaries, issues of helping and power, supervision, beginnings, and endings. Chapter 6 addresses shared constructions of meaning in communication with constituencies that extend the local toward a more global

focus for practitioners and clients as seekers of mutual meaning in complex phenomena. My focus is on the exchange of thoughts, feelings, and information, presenting communication as a concept bound by culture and context. Ethical global practice requires intercultural communication that considers changes in the mode, quality, and quantity of interactions brought about by technological developments. I also consider the importance of social workers’ communicating with a wider public and their use of tools to record and analyze their interactions with others, including clients, supervisors, and team members. Critical consciousness, reflection (considering what happened and what should follow), and reflexivity (increasing awareness of personal assumptions) for differential use of self are examined in chapter 7. These concepts allow practitioners to develop self-awareness along with deep knowledge of the profession and its ethical guidelines so that they can base practice on social work’s values and the client’s needs; continual observation and thought allows workers to identify and remain aware of their personal values in order to keep them separate from their professional behaviors. Chapter 8 explains and illustrates strategic interventions as directed by evidence, best practices, and case theory and supported by emerging normative theories and concepts such as ecological approaches and ethics of care. These interventions include the statement of the problem, short- and long-term goals and goal-setting, and evaluation, all of which relate “what” is done to “why” it is done. I also discuss challenges of cross-cultural practices across and within national borders as social workers act to protect from harm and provide for necessary concrete services within a framework of promoting social justice and enhancing human well-being. Best practice is therefore highly complex and requires a wide range of data sources to support intervention decisions that result in good outcomes for clients. From this perspective, data are not limited to information

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gathered from clients and other related people and professionals; they must also come from research, concepts, theories, and approaches discussed in the professional literature. Peerreviewed journals, books, and a range of statistical material (census figures, United Nations reports, etc.) on populations and problems pertinent to situations faced by clients add critical information, and most are easily accessible in our networked world. Most chapters conclude with exercises, examples, and discussion questions. Practice Theory Readers of this book will acquire a conceptually grounded framework through which to organize each practice component into a dynamic whole. Bertha Reynolds, one of social work’s most important teachers, long ago recognized the need for practice theory: “The security of having at least a core of theory common to all of social work, and of seeing it in a dynamic way, so that change can be welcomed instead of feared as new data come, is one of the greatest needs of social work in our time” (Reynolds, 1942 [1965], p. 8). In this book, we see how assessment directs relationship and communication yet is dependent on client trust and on the shared meanings. It also becomes evident that without assessment, intervention takes place in a vacuum, and without differential use of self, interventions may cause harm. Siporin (1975) discusses the value of practice theory in providing “a structure of ideas that we use in helping people” (p. 118). This practice theory was informed by the social work practice literature, the CSWE accreditation guidelines, the NASW standards (NASW, 2008 [1996]), and multiple codes of ethics (British Association of Social Workers, 2002; Canadian Association of Social Workers [CASW], 2005; IFSW & IASSW, 2004), as well as by analyses of case material provided by social workers through intensive interviews and audio and video material. Treatment theories such as narrative or cognitive-behavioral therapy or

theories of diagnosis such as attachment or social isolation address specific client problems or populations or help guide assessments. Distinct from these theories, social work practice theory, along with the profession’s values and ethics, sets a foundation for ethical decision making about which of these other theories to use for assessments and interventions. Theory building is continuous; new problems require new knowledge about human development and about the social world. These social work domains are constantly in flux. The relationship of biology to psychology was viewed as somewhat fixed in the 1950s; family therapy as a field and modality of practice did not become widely accepted until the 1970s; AIDS was not a problem until the 1980s; and in 2010, debates began about eliminating Asperger’s syndrome as a separate category from the Diagnostic and Statistical Manual of Mental Disorders (DSM) and to fold it in as an “autism spectrum disorder (ASD)” Tensions continued into 2014 about this change: some families welcome the shift to a continuum, and others worry about decreased support—financial and biopsychosocial (Baron-Cohen, 2009; Carey, 2012; Grinker, 2010). New practice environments and technologies and previously unknown problems will create needs for new theories just as the components of practice theory must evolve to address changes in people and environments. Practitioners need both kinds of theory to understand and explain the situations in their work and help address thorny questions such as whether categorizing Asperger’s syndrome as an ASD in the DSM V was positive. Practice theory rationalizes the art of social work in ways that specific assessment or intervention models cannot. While the primary focus in this book is on change with individuals, practice theory that rationalizes the art of social work provides a way of thinking about direct and clinical social work practice to build linkages between what is done and why it is done across these multiple levels and from a biopsychosocial perspective that recognizes problems in social functioning

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as a function of biological factors, psychological issues, and the social context (Bisman, 1994). Users of This Book This foundational practice text fully meets accreditation expectations for practice in the United States and covers issues pertinent to practice in other nations. Adhering to current CSWE (2008) Educational Policy and Accreditation Standards (EPAS) and to those emerging for 2015, these chapters embrace a human rights viewpoint and teach for competence in evidence-based practice with a personin-environment and strengths perspective; biopsychosocial assessments; attention to a global world; critical thinking accompanied by reflection and reflexivity; policy practice and advocacy; integration of multiple sources of knowledge; effective oral and written communication in working with diverse individuals, families, groups, organizations, communities, and colleagues; engagement, assessment, intervention, and evaluation with individuals, families, groups, organizations, and communities. To meet these accreditation guidelines, all chapters draw from the ethical codes of the professional organization that sets standards for practice in the United States (i.e., NASW) and from those of the international organizations— the International Federation of Social Workers (IFSW) and the International Association of Schools of Social Work (IASSW)—for ethical decision making in practice. Coverage emphasizes respect for human diversity, the value base of the profession, and its ethical standards in recognizing and managing personal values to ensure that professional values guide practice. Cases, Narratives, Practitioners Comments by social workers accompany all the case studies and narratives and are central to understanding the concepts presented throughout the text. Information about the social workers includes facts about their upbringing and their cultural backgrounds and provides a fuller picture of what it means to be a social worker

in practice with clients; this helps us identify with them as real people who are working in challenging situations. Furthermore, knowledge about their own values and qualities helps us to understand their decision making and appreciate the impressive diversity within our profession. Personal and background information reveals them as a diverse population on the variables of race, disabilities, class, sexual and gender orientation, and ethnicity, among others. Social workers present their cases, which cover a range of practice areas and populations, including child welfare, illness, gerontology, substance abuse, reproduction, school social work, family problems, violence, sexuality, death and dying, discrimination, and poverty. Acquired from various countries, cities, and regions, these cases (many followed through different chapters) illustrate practice to alleviate oppression and promote civil society that is relevant domestically as well as globally. Note that to adhere to confidentiality guidelines, the case studies and narratives for each chapter section include a range of locales rather than the specific city or nation for each case. Moreover, for confidentiality of clients and social workers, names have been changed in all cases, and no one has been presented in his or her actual employing agency or geographic locale. Identifying data have been shifted so that individuals cannot be connected to the facts about them. Some cases are composites, and some have been discussed in other books (Bisman, 1994; Bisman & Hardcastle, 1999). Yet the thrust of analysis in all cases is on global and critical consciousness and a values/ethics perspective. Finding neutral terms was a struggle, and so was deciding to specify the many differences among social workers and clients despite arguing against relying on dated notions of ethnicity and race, among other variables. The context of cultural backgrounds and socioeconomic location became necessary in exploring when these variables are relevant to practice and when they are harmful. It is hoped that learning about cases directly from the social workers

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themselves helps readers to practice both the art and science of social work. “Clients” is used inclusively to refer to individuals, families, groups, organizations, and communities (NASW, 2008 [1996], p. 2). YYY

To become a social worker is to enter a profession that challenges with ambiguity and fulfills with change toward the common good. Through work on the social welfare, social workers deal with public matters and personal troubles. A cookbook approach cannot adequately cover the intellectual and emotional journey necessary for effective social work practice. Instead of recipes, social workers need to draw from a wide range of knowledge in order to develop understanding and use skills that fit the unique needs of each

client. This requires recognition that professional practice is both science and art. In her admonishment that “the real world is not an exam,” Zuger advocates for less emphasis on test scores of medical students which don’t prepare them for “complicated, contradictory cases for which there were no clear ‘best’ strategies, but many reasonably acceptable ones” (2014, p. D4). This book examines how social workers draw from theories and the empirical world, despite difficulties in applying scientific rules or verifying data, to inform the aesthetics of practice—their creative integration of material to fit the unique lives and idiosyncrasies of human beings and their communities within social work’s values and ethics framework— toward the moral ends of human well-being and social justice that imbue the profession with its purpose and define the role of social work in society.

2 Organizing the Ideas of Social Work

When . . . social workers have a conception of development and advance which “includes” both the welfare of the individual and of the mass . . . social work will at last come into full possession of itself and of its rightful field of service. —Mary Richmond, social work pioneer Social work is about making positive differences for people and for the communities in which they live. In my 20 years of practice, the hardest thing for me has been managing my role in the organization and the sometimes problematic service delivery. The biopsychosocial perspective guides everything I do as a practitioner; it is not possible to provide effective services to kids in schools without paying attention to conditions such as whether they need medications, their social world, and how well the school is educating and serving their needs. —A social worker

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eal-world problems—deciding whether to medicate a 4-year-old child with serious behavior problems or considering options with a 14-year-old girl raped by her uncle and now pregnant—confront professionals with serious epistemological and methodological challenges. There are no standard models or general laws for these problems, and the concrete solutions (the means of intervention) may differ radically depending on the unique circumstances of the clients. All professional occupations are similar in their need to analyze a problem situation in order to apply knowledge to obtain outcomes that alleviate the problem. Judgment on the part of a profession’s members

is critical in deciding which knowledge to use and what outcomes to seek for effective practice. Interactions with clients shape the content discussed, often making understanding of an objective reality mostly illusory. Meanings that clients and professionals attach to particular experiences and styles of communication vary, making shared constructions difficult, yet these are necessary for effective practice. Moreover, successful outcomes require from clients accurate information and adherence to a treatment regimen, along with follow-up actions by professionals relevant to the unique needs of each client. This chapter presents a description of professional occupations, which is followed by a focus on social work as a profession and its major organizing ideas. Inherent in the historical roots, mission, and values of social work are two core paradigms: the first is the person in environment perspective with its attention to the troubles of individuals, conditions in the community, agency service provision, and the social policies that affect the lives of individuals. The second paradigm, biopsychosocial practice, requires incorporation of physiologic factors (chemistry, neurology, genetics, physiology) with the psychological (cognitive, affective, and emotional functioning) and gives special attention to the social (community resources, social supports, income, education, and housing). Interactions among the broad domains covered in both of these core paradigms shape human functioning, and case studies illustrate how social work practice reflects these organizing ideas. 9

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Professional Occupations The concept of “profession” is itself an ideal— a construction to make sense of work that is driven by a moral commitment to serve the community toward a greater good by creating change in some public phenomena such as injustice, illness, social disorder, or education. This feature most distinguishes professions. Service to the society, shaped by a profession’s values and ethics, is unique to professional occupations, and an ethical code emerging from a profession’s service mission distinguishes professional occupations. Gustafson (1982) emphasizes the primacy of service and the importance of a moral foundation for professional occupations: “A calling without professionalization is bumbling, ineffective, and even dangerous. A profession without a calling, however, has no taps of moral rootage” and cannot “envision the larger ends and purposes of human good that our individual efforts can serve” (p. 514). It is this service mission and its implicit values that drive a profession’s specialized knowledge, ethical code, and practice skills. Social work’s status and authority is lower than that held for the legal or medical professions. This is partly a consequence of its broad base of knowledge, primarily located in the public sphere, and its high commitment to service. Historically, users of professional services have relied on the professional’s judgment: The exchange on the part of the client is trust in specialized expertise that will provide competent help to alleviate a problematic situation. Nonprofessional occupations serve customers, who choose their purchases and can obtain a refund if not satisfied. Although Jane Addams considered those who lived in her settlement as “citizens-in-the-making” rather than clients, many professions today retain use of the terms “clients/patients.” Nonetheless, there have been efforts by some social workers to change the language to “consumers,” such as in mental health, and to “service user” in the United Kingdom (Clifford & Burke, 2009).

In recent times, the power of the professional’s monopoly of judgment has begun to weaken: It is now not unusual for clients to shop around for the best professional and to make their own decisions on which services are needed. Insurance companies often require second opinions on medical recommendations for surgery, and legal suits against professionals are common. The service function is also at risk from increasingly high fees and shrinking public service, especially evident among some lawyers and medical specialists in the United States. The norm of public service of professions emphasizes that clients’ problems must supersede practitioners’ self-interests and that clients are not to be exploited; decisions to offer services should be based on clients’ need for help, not practitioners’ need for remuneration. Unlike some professions, social work practice is primarily carried out in the public sector in the United States (although there has been an increase in for-profit social services) and especially so in the United Kingdom. Even those social workers employed in for-profit settings and in private practice address issues that pertain to the public sphere. Those entering the social work profession are considered to be strongly committed to a calling to serve and to altruism in seeking to enhance human well-being and promote social justice. Extraordinary developments in technology have increased the rapidity of change during these early years of the 21st century. Medical practice relies heavily on electrocardiogram (EKG) measurements of heart rates and on magnetic resonance imaging for finding cancerous tumors. Social work practice now looks quite different from, yet shares some similarities with, practice in the early 1900s. More lifestyle options for men, women, and lesbian, gay, bisexual, and transgender (LGBT) individuals have altered traditional notions of family life, while massive border crossings by people in many parts of the world have marked the beginning of both the 20th and 21st centuries. Indeed, movements of people

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across continents now takes a much shorter time, information transmission is fast and easy, and access to information is relatively inexpensive. These transformations affect the conduct of work, including that of professional occupations. Record-keeping is increasingly digitized, creating challenges for confidentiality and privacy but allowing for direct communication among a range of providers. Location is not as important: Satellite clinics in far-flung places can still be connected to the main hospital or child welfare office. Drucker (2002) believes we have entered the “knowledge society” in which high-knowledge professionals will be joined by a range of technical experts who consider themselves professionals rather than “workers,” further expanding the upward mobility offered by professional occupations. Just as their knowledge base is continually in development, professional occupations are continually in formation, being shaped by their history and by contemporary social norms. Members of professional occupations must change and adapt to these challenges yet retain some of the core traditions and adhere to the values and missions of their professions. Justice Oliver Wendell Holmes (1881) states in The Common Law, “The life of the law has not been logic; it has been experience. . . . In order to know what [the law] is, we must know what it has been, and what it tends to become” (p. 1). Education for a profession involves personal change as its students adopt a way of thinking about phenomena. Socialization is an ongoing process starting at birth and continuing throughout life. The focus in childhood is on learning about and integrating the norms and culture of one’s family and of the larger society; during the adult years, further socialization builds on these early attitudes and skills. Those joining a professional occupation go through a similar socialization (Miller, 2013) in acquiring the profession’s skills and knowledge and assimilating its norms into their identity as individuals and professionals.

Social Work Becoming a Profession Similar to other professional occupations, the practice of social work takes place in the current and very real world to address contemporary problems and maintain social order, yet it also draws from historical traditions about its practice and domain, connecting to earlier social welfare approaches with differing values and norms. Such socialization is located in the art, not the science, of the social professions. This is a term used in some European nations for a range of occupations that address social services for people in need (Clifford, 2013). Social work is inherently political in its concern with social policy and with influencing social policy’s regulation of social behavior, connection to public and civic affairs, and the community’s distribution of social statuses, privileges, and other resources (Banks & Nohr, 2003). Theories and technologies have emerged, and more are needed to address new challenges faced by individuals and their social worlds. To illustrate this we consider, albeit in a very cursory way, the early traditions that inform the social work profession and the professionalizing process for social work. Early Welfare Traditions The tradition of religious charity offers a prehistory of social welfare services. Medieval canon law in the Middle Ages reflected the Catholic Church’s emphasis on charity, offering care and protection of the poor. Tierney (1959) explains that ecclesiastical law included several provisions to protect the poor, including maintenance of legal rights, exemption from court fees, and provision of free legal counsel. Canonists agreed that the church had a special duty to protect “wretched persons”; poverty was viewed as an affliction, not a defect. As Sahlins (1972) points out, in traditional societies “poverty is not a certain small amount of goods, nor is it just a relation between means and ends; above all it is a relation between people . . . a tributary relation” (p. 18). Slack (1988) compares this attitude to those in early modern England where

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the wealthy were in danger of eternal torment if prideful of their riches, which were not considered their own but held in trust for the poor as stewards of the Lord. “Charity encompassed . . . love of all one’s neighbours; hospitality should be extended widely, to neighbours and strangers alike” (Slack, 1988, p. 19). As England became a more secular society, attitudes toward the poor and services for them shifted. During the reign of King Henry VIII in the early 1500s, the civil parish evolved from its medieval counterpart and considered poor relief one of its responsibilities. Along with local assessments for upkeep of churches, street cleaning, and bridge maintenance, “rates for the poor were one further expression of the responsible local community fulfilling its obligations” (Slack, 1988, p. 131). Guided by some of the precedents from these years, the Elizabethan Poor Law of 1601, established basic strategies of poverty relief that were followed until another set of major changes was introduced two centuries later in the Poor Law of 1834. Two principal assumptions from these poor laws, however, continued through most of the 20th century— state acceptance of responsibility for the social welfare of its citizens, and implementation of a complex apparatus to deliver services. Slack (1988) emphasizes their extraordinary achievement and believes that in 1700, the scale of the English welfare system had no parallel in Europe: “in looking out for the poor, Englishmen were also exhibiting a refusal to tolerate misery and deprivation” (p. 206). Though contemporary standards might view the benefits as meager, within the context of those years the laws were radical and humane. By the end of the 18th century, there were clear distinctions between poverty (those whose only property was their labor) and indigence (those in misery and distress who needed alms to survive). Growth of towns and concern for cleanliness and appropriate behavior complicated perspectives of the poor. Though for some the poor were pitied, blamed for their weakness, and viewed as a threat to public morality and public health, for

others they were a potential productive resource needing training and services (Slack, 1988). All of these competing views persist today. Professionalization of Social Work Education The Early Years Along with inefficiency and religious prejudice, early social workers were criticized for practicing in: “the only field of human action in which . . . good intentions take the place of training” (Masterton, 1888). A model of education including a combination of apprenticeship, supervision, and lectures focusing on actual work in agencies was developed in England by collaboration between the Charity Organization Societies (COS), the Women’s University Settlement in Southwark, and the National Union of Women Workers (Smith, 1965, p. 22). By 1896, today’s model of mixing didactic information in formal classes with on-site supervision was established. The first School of Sociology, founded by the COS in 1903, joined with the London School of Economics in 1912 and became the Department of Social Science and Administration. Reverend Henry Solly declared “this is the science of doing good and preventing evil in our social system” (cited in Woodroofe, 1964, p. 48). Such changes were also occurring in the United States, with Mary Richmond advocating for inclusion of both the practical and the theoretical in educating for “the profession of applied philanthropy” (1898, p. 186). In 1898, the New York COS offered a six week Training School in Practical Charity (Woodroofe, 1964), which ultimately became the Columbia University School of Social Work, followed by social work programs at Chicago and Simmons. Richmond’s work to advance the profession was further spurred by a report on educating doctors by Abraham Flexner (1915), who asserted that in comparison to the established professions of medicine, law and engineering, social work lacked a distinctive method and scientific body of knowledge. In addressing Flexner’s criticisms, Richmond ultimately met her goals for a “more highly organized body of knowledge”

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(Richmond, 1930, p. 100) and “the development of higher ideals of charitable service” (p. 104). In developing the Social Diagnosis as the profession’s method, “the primary purpose of the writer, in attempting an examination of the initial process of social casework, is to make some advance toward a professional standard,” she provided a method and knowledge base that continues to guide the profession (Richmond, 1917, p. 26). Systematizing gathering data about the client’s history and the critical linkage of diagnosis to intervention: “Social evidence, like that sought by the scientist or historian, includes all items which . . . throw light upon the question at issue; namely as regards social work, the question what course of procedure will place this client in his right relation to society?” This is discussed more fully in the later chapter on assessment (Richmond, 1917, p, 39). Individual Change and Social Reform Jane Addams through her development of the settlement movement and Mary Richmond through her work with the COS are the most significant figures in the history of social work in the United States. The COS emphasized charity relief (direct services) and individual change and called its volunteers who provided treatment the “friendly visitors,” whereas the settlement house movement workers sought community changes to assist the settlement of immigrants and improve social conditions. Settlement workers engaged in political action for social change with focus on issues large and small—sanitation, recreation, daycare, and literacy classes—and helped to found the National Association for the Advancement of Colored People (NAACP) in 1909. These dual roots define and distinguish the social work profession. Nevertheless, to this day what should be viewed with pride is more often a source of tension and divisive: simultaneous attention to both individual change and social reform remains a challenge in the theory and practice of social work. In one of her first works, Richmond (1899) eloquently states,

“We must know how to work with others, and we must know how to work with the forces that make for progress . . . to forward the advance of the . . . people into a better and larger life” (p. 151). Later, in one of her lectures to students at the New York School of Social Work, she passionately pleads for reconciliation between social reform and work with individuals: When social movements, social agencies, social workers, have a conception of development and advance which includes both the welfare of the individual and of the mass, which reconciles these two points of view and assures the permeation of each by each, then the upward climbing spiral . . . will no longer lose its balance and momentum by swinging violently from one side to the other. It will take a far wider, firmer sweep in both directions, it will cover more ground more symmetrically. In some such way as this, as I see it, social work will at last come into full possession of itself and of its rightful field of service. (Richmond, 1930, p. 584)

From charity work to child welfare, social work practice expanded to schools and medical and psychiatric hospitals, widening its areas of employment and its services for clients. In addition to their broad social reforms, the settlement workers used a range of approaches still highly significant today including client advocacy, policy practice, group work, selfhelp, and community organization. In addition to civil rights, they are recognized for reforms such as the labor movement and public welfare: Addams embraced social feminism and engaged international issues. For further elaboration of social work’s history, see Gilchrist, Jeffs, and Spence (2001), Leiby (1985), and Pumphrey and Pumphrey (1961, 1964); see Bisman (1994, 2004) for the professionalization of social work. See Elshtain (2002) for an excellent historical account of this period and of the life of Jane Addams. Social work has been criticized for a lack of coherent theory and a heavy reliance on

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knowledge from other disciplines, including sociology, psychology, medicine, and psychiatry. Its advocates argue, however, that the wide scope of social work’s person in environment— simultaneously encompassing social reform and individual change—necessitates creative borrowing and integration of knowledge and theory from many sources. They further point out that many professions increasingly draw broadly from a range of sources (Held, 2006; Clifford & Burke, 2009). Contemporary Perspectives While there are variations across nations, it is common for most professional occupations to guide their practices through ethical codes, to develop curriculum, and to function as “gatekeepers” by controlling the process of admission to and graduation from the educational programs that are themselves accredited by members of the profession. Certification, licensure, and education all restrict admission to professional practice. In the United States, the National Association of Social Workers (NASW) is social work’s primary professional organization. It handles certification via a review committee structure created in 1987 “to provide expert professional and technical judgment necessary to ensure the validity” of its professional certification, the Academy of Certified Social Workers (ACSW). The president of NASW, elected by the NASW membership at large, appoints committee members. NASW also handles credentialing as the profession expands into new areas to respond to societal changes and individual needs. One of its core functions is development and revision of the profession’s code of ethics, and NASW has the responsibility to form ethics panels to hear complaints about the ethical behaviors of social workers and to censure such workers if necessary. Initiated to protect the public, licensure is a function of state boards composed of representatives from the public at large and members of the profession. Regulations vary from strong social work licensure in Kansas

to a weaker model in Pennsylvania (in some U.S. states, individuals can practice social work with no license). Both certification and licensure require a candidate to pass examinations. Certification has become less common with the increase of licensure. Heavily used by direct service and clinical social workers, licensure allows for insurance payments to cover services, and some agencies will only hire licensed social workers for their own protection from malpractice suits and to ensure a minimum of expertise. In the United States, accreditation of social work programs is the responsibility of the Council on Social Work Education (CSWE). Formed in 1952 to establish educational standards for master’s degree programs in social work, its role has expanded to faculty development and to creation of a rigorous accreditation process that now includes a majority of bachelor’s degree (bachelor of social work; BSW) programs—as of February 2014, 492 programs, with the master’s degree (master of social work; MSW) offered by 231 programs. Unclear distinctions in the United States between these two levels of entry into practice have at times generated confusion for the profession and the public. Although autonomous practice has been associated with the MSW degree, the title of social worker is used by graduates of undergraduate or graduate programs. Whereas NASW’s code of ethics focuses on the behaviors of individual social workers, CSWE’s concern is with the educational programs. Its Commission on Accreditation (COA) develops standards for competent preparation of social work students: These standards require institutional self-studies, site visits by a team of COA-trained educators from other accredited programs, and periodic program reviews for reaffirmation. CSWE regularly updates its Educational Policy and Accreditation Standards (EPAS), and recent additions to these standards require international content in the curriculum of U.S. social work programs (Council on Social Work Education, 2008).

ORGANIZING THE IDEAS OF SOCIAL WORK

In the United Kingdom, debates about social care versus social control have been more heated as the state has begun to exercise greater authority over the social work profession and control over “unruly or anti-social behaviour [from child abusers to child criminals]” (Banks, 2004, p. 36). On the whole, government in the United Kingdom is more heavily involved in curricular development for social work (Friedson, 2001; Hugman, 2005). As in the professions of teaching and nursing, women in social work have vastly outnumbered men; in 2004, the ratio was more than 4 to 1 (National Association of Social Workers [NASW], 2008 [1996]). While the feminization of women’s roles in the latter half of the 20th century did help to facilitate the professionalization of social work, there is still a widely held perception that social workers are primarily “do-gooder women who interfere in the lives of others.” Issues of class and gender have had an impact on the view of social work as a profession with “lesser” status than that of medicine and the law. Yet, there have been shifts: a major shift is in the class background of those entering social work educational programs—from the wealthy of the early “friendly visitors” to low- and middle-income women and, to a lesser degree, men, all finding education for social work a means of upward mobility (Schultheiss, 2001). Social Work’s Person in Environment The contemporary person in environment perspective, initially developed by Gordon (1965) and Bartlett (1970), emerges from and further builds on the dual roots of individual change and social reform. Social workers are to target change with individuals and in environments. Though the emphasis will vary, both individuals and their environments are considered together to enhance human well-being and to promote social justice. This orientation “views the client as part of an environmental system . . . encompasses the reciprocal relationships and other influences between an individual, relevant

others, and the physical and social environment” (Barker, 2003, p. 322; NASW, 2005, p. 9). In this book, person in environment includes people individually or in families or small groups. Environments cover local neighborhoods and broader communities, organizations, and social policies. Social workers engage with individuals to help them better negotiate their environments, and they intervene with environments to serve the needs of individuals better. Notwithstanding that other professionals may address similar issues and concerns and may use the same areas of knowledge, this focus on simultaneously creating change with people and with the social world remains unique to social work.

Therefore, for effective practice in the area of substance abuse, in addition to direct counseling social workers need information about state and federal policies as well as familiarity with rehabilitation programs and other approaches accessible in the community. Likewise, knowledge about city, state, and federal immigration policies and appropriate medical settings is critical in providing services to a young pregnant woman who is not a U.S. citizen; additional information would also include her social support networks, financial and employment status, and potential educational/vocational opportunities to enhance her future stability. Social workers must be sure “to not cause harm” and also to advocate for and empower clients through attention to these multiple levels of practice. Case studies throughout this book illustrate such practice. For example, in a placement that provides services to families and children, Linda advocates that her setting expand with a satellite office to provide services to people in need. To empower and protect a woman who wants to leave her husband because of abuse, Karen needs to know which shelters are safe and available and whether they take children (when needed). At the same time, Karen must have knowledge of policies for protection of abused spouses while she also uses her knowledge and direct practice experience to inform policy change.

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Multiple Levels of Practice The person-in-environment paradigm with its multiple levels of components—societal policies and regulations, the community and its resources, the service delivery of the agency, small groups and families, and individuals—is discussed in the preamble to the NASW Code of Ethics: “Clients” is used inclusively to refer to individuals, families, groups, organizations, and communities . . . activities may be in the form of direct practice, community organizing, supervision, consultation administration, advocacy, social and political action, policy development and implementation, education, and research and evaluation. . . . Social workers also seek to promote the responsiveness of organizations, communities, and other social institutions to individuals’ needs and social problems. (NASW, 2008 [1996], p. 2)

Contributing to the profession’s ongoing struggle to reconcile its divergent roots may be the ambiguity and even elusiveness of its primary concepts. In the subsequent sections of this chapter, the definitions and explanations of the practice levels of social work are followed by illustrations and further discussion. Policy Practice Social policy determines to a large extent the functioning of the profession, including what its practitioners do, their clients and colleagues, and how they get paid (Hardcastle, Powers, & Wenocur, 2011). Policies mandate the provision of services and allocate the resources for funding and implementation of programs (Jansson, 2008). Improving the situations of clients through policy practice requires knowledge about existing policies and about potential client needs such as income, food, housing, community safety, child welfare, and school-related issues, among others. Determinations for apportionment of services and subsidization of costs are usually difficult and often require intensive planning to be equitable and reduce

favoring of some groups over others. As social constructions, policy formulations involve negotiations between competing interest groups representing conflicting needs, unequal access to resources, and often different meanings attributed to the problem and to the policy (Alexasti, 2002). Social policy is the social context that provides the goals for social development and the parameters for social control. Current values and mores, cultural traditions, religious beliefs, and scientific and technological knowledge all affect policies and practices. Social work practiced during the time of Richmond had somewhat different concerns than social work today, just as issues during the middle of the 20th century have shifted during the early years of the 21st century. Abortion remains contentious but legal in Europe and the United States (although that seems to be turning back again); the normative role for women is still changing with broader options and autonomy in some nations and violent oppression in others. Contemporary practitioners face a perpetually changing landscape in family structure and marital options for the LGBT population depending on their particular state of residence in the United States or on their nation of residence. Social, legal, economic, and medical developments and policies in a society profoundly affect the practice of social work. Even though social workers addressing their attention to change in individuals may not be involved in direct policy decisions, ethical practice requires that they have knowledge and capacity to advocate for policies that promote social justice and alleviate oppression. As Moody (2004) points out, policy practice interventions in hospital settings are now necessary, as many social workers find themselves facing ethical challenges around manipulation of diagnoses in order to lengthen hospital stays, increasing revenue for the setting at possible risk to the clients. Jansson (2008) defines policy practice as “efforts to change policies in legislative, agency,

ORGANIZING THE IDEAS OF SOCIAL WORK

and community settings, whether by establishing new policies, improving existing ones, or defeating the policy initiatives of other people” (p. 14). Others, including Hardcastle et al. (2011), Gammonley, Rotabi, Forte, and Martin (2013), and Mosley (2013) agree that policy practice and advocacy is a primary function of social workers and a core competency in social work education. Effective policy advocates are committed and informed, make assessments and engage in strategic planning, and use assertiveness. Those engaged in private practice are also involved in matters of policy in a variety of ways. As Clifford (2012) points out, “What may appear to be a very personal problem . . . will be directly or indirectly influenced by the political or policy decisions of governments and organizations” (p. 188). Moreover, strict licensure laws that strengthen social workers’ authority to make diagnoses and receive reimbursements from third-party vendors have been strongly advocated by the Clinical Social Work Societies. Knowledge of policies is integral to obtaining payments, and facts about the tax laws assist in accurate claims for deductions. Some social workers concentrate in policy practice and, similar to those in community practice, must keep in mind the needs of individuals and families, although the thrust of their work is on policy change. Child abuse offers an example of the strong ties between policy and practice and the powerful impact of geography and culture. In the Western world, views about the worth and care of children have changed drastically: The increase of the middle class and decrease in the need for income from children’s work allowed for changing attitudes toward child labor (in mines, factories, farms, etc.) accompanied and followed by changes in mores and values. Society became responsible, sometimes instead of the family, to assure children a protected environment (protected even from the family if necessary). Child abuse has now become one of the predominant problems for social workers

(in the United States and United Kingdom) who address abuse across economic and social classes and in all racial, ethnic, and religious groups. Just as in the early years, issues raised in practice will continue to influence funding decisions and policy planning for child abuse programs, while policy decisions affect the availability and quality of direct services. More recently, new problems have emerged with forprofit corporations weakening the protections of children. Bakan (2011) points to the relationships between childhood obesity and the selling and marketing of junk food and to pharmaceutical companies pushing untested medications for use on children, among other areas needing policy and practice attention. For a very different example, we consider the failures of this Western (Anglo-American) approach of “child protection” in South Africa, where it has been viewed as remedial and punitive. Schmid (2007) argues for a developmental social welfare framework that addresses economic and social issues as part of child well-being, a “holistic, family-centered, community-based, strengths-informed” set of practices (p. 500). She believes that international social work must allow for “alternative and indigenous” policy perspectives in order to advance child welfare (see also Hendricks & Fong, 2006; Patel, 2005). Cox and Power (2006) explore the increasingly politicized field of displacement and forced migration, pointing to the need for global social work efforts to affect immigration, repatriation, and resettlement policies, as well as program development for services to individuals, families, and communities. And some are concerned that globalization itself may impede the necessary policy planning needed to address these global issues. Growing inequalities between nations may result in more divisiveness rather than collaboration (Harris & Chou, 2001; Lyons, 2006; Townsend & Gordon, 2002). Tensions for those in policy practice include continuing attention to the individuals and communities in need. Good sources about

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social work practice and policy include Barusch (2002) and Jansson (2008). Social policy guides the practice of social work and determines what social workers do and how they are paid. It is the context that provides the goals for social development and the parameters for social control. Ethical practice requires knowledge and skills to advocate for policies that promote social justice and alleviate oppression. CASE STUDY: RHONDA AND CHILD

3 years. Changes in social norms about family life and child abuse—historically one of the primary domains of social work—continue to shape laws and practice in child welfare services. The Child Abuse Prevention and Treatment Act (CAPTA), originally enacted in 1974 and amended and reauthorized in 2010 (P.L. 111-320), establishes general categories of abuse recognized by the federal government and allowed the states to create specific definitions of abuse (Child Abuse Prevention and Treatment Act, 2010, P.L. 111–320). Rhonda states:

WELFARE—INFLUENCING POLICY

In chapter 7, we discuss the practice of Rhonda as she confronts her own reactions to a highly complex case of child abuse. Currently employed with child protective services in an urban area, Rhonda has had 10 years of post-MSW experience. After graduating college (under a full scholarship), she got a job in a large urban public welfare organization but felt unprepared for the high caseloads and complex situations. Taking advantage of the agency program that paid for a master’s degree in social work, Rhonda in turn “owed” the agency 3 years of continued employment. (Case material here is a composite from a case discussed in Bisman, 1994.)1 Married to a lawyer, with two children in their early teens, her household income about $170,000 a year, Rhonda had a lifestyle that as a child she could not have imagined. She didn’t want other children to have the hurts she experienced, including sexual abuse by an uncle when she was 7, abandonment of the family by her father, and her mother’s depression, lack of employment skills, and need to live on welfare payments. Although at times overcome by the brutality in some of her cases, she has stayed well beyond the

1. Locales for the case studies presented in this chapter could include Arlington, VA; Baltimore, MD; Bronx, NY; Brooklyn, NY; Cardiff, Wales; Durham, England; Edinburgh, Scotland; Kansas City, KS; London, England; Luton, England; Minneapolis, MN; Newcastle, England; Newark, DE; Newark, NJ; New York, NY; Oxford, England; Philadelphia, PA; Queens, NY; Topeka, KS; Washington, DC.

As I see more and more adolescent girls becoming my clients as mothers abusing their young children, it’s so sad for me—I placed some of these young mothers when they were abused as children. Drugs are almost always part of the problem now. All that stuff about policy taught in social work school seems so much clearer. We have to somehow get into the business of prevention—including policies around birth control, drug treatment, and education for our children. These girls drop out when they’re so young, and once they realize how trapped they are, it’s too late. They’re often bitter and frightened and take it out on their kids. With our caseloads so high, it’s hard, but I try to build coalitions with colleagues. Active in the local chapter of our professional social work association, NASW, we lobby state and federal officials for additional monies and also inform them about needed policies. In my state the statutes remained vague, yet several cases had recently gained much public attention, placing pressure on the agency for stricter supervision of families and more stringent regulations. At the same time there were funding cutbacks resulting in a hiring freeze and a backlog of reported incidents with no agency contact. We seem constantly on a treadmill. I also volunteer, through the local school board, to talk with groups of students, encouraging them to stay in school, and even offering some tutoring. Active in my church, I occasionally give talks about recognizing abusive behavior and offer alternatives to parents for the expression of angry feelings.

ORGANIZING THE IDEAS OF SOCIAL WORK

I am increasingly called on to give court testimony and work hard to be knowledgeable about existing regulations yet also draw on my expertise and knowledge to suggest necessary policy changes. Who would understand better the limitation of current policy than me and the others working directly with the laws? Likewise, I think I can be more powerful in informing the public and lobbying for the allocation of funds than legislators who do not have direct experience. Note the breadth of Rhonda’s efforts—directed to educating for prevention of abuse and for increased funding and public support of these services. She has come fully to recognize her obligation to be involved with policy issues in order to be of help to her individual clients. In chapter 7, Rhonda speaks eloquently about the trauma for all parties involved with child abuse, her feelings of shame about her childhood, and her then-worries that other children would find out about her home situation. She also discusses challenges because of racial differences. Rhonda is black, and clients in her caseload have diverse racial and ethnic backgrounds and come from many nations including the United Kingdom, India, South Korea, and Togo.

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CASE STUDY: BRENDA WITH DORIS AND HENRY MILLER—POLICY PRACTICE

We now consider Brenda’s practice at a family services setting in a major U.S. metropolitan area. Thirty-five years old and bisexual, she and her female partner of 5 years were legally able to marry in the past year. Her 8 years of social work experience have been split between 4 years on a hospital medical ward and 4 years in her current position at a family services setting. (Brenda’s practice is also discussed in chapter 7.) I see a range of clients, sometimes single males and females as well as gay couples. Doris and Henry Miller are a heterosexual, biracial couple

in their mid-thirties. I had seen Doris for individual therapy that lasted about 4 months about 2 years before, early in their difficulties with conception. After several years of seeking pregnancy with no conception, they had approached a fertility clinic that requires genetic counseling from someone outside the clinic. Both were employed professionals, she a librarian, he a computer programmer, with good health insurance that did not include coverage for infertility. The Millers had saved more than $50,000 for in vitro fertilization (IVF) and/or adoption. Tests over a 2-year period have not offered any explanation for the infertility, and the couple was seeking an assessment about their readiness for IVF and use of their own gametes (egg and sperm) or those of a donor. They have already spent more than $15,000 on one IVF cycle with their own gametes that did not work. The Millers were apprehensive about pursuing adoption having heard “horror” stories about the intrusiveness of the process; they didn’t want their privacy invaded yet also recognized the state responsibility to protect children from potentially abusive home environments. I see several policy issues in this case. Often these clinics “want the business” (and indeed, IVF and adoption proceedings are profitable ventures for the agencies), so they may not provide the extensive counseling that couples need and even request; I always pay close attention to the relationship between finances and services. In this situation, the couple was required to get an assessment from an “outside” professional—this is a good, albeit not usual policy because it affords the clients an opportunity for a sound assessment not biased by financial benefit to the agency. To do this work, I must be informed about state laws. I needed to know the laws regulating assisted reproduction and adoption procedures (would a biracial couple be at a disadvantage?) as well as the costs for IVF and for adoption. Other policyrelated questions that concerned me were the workplace environment: were daycare and flextime available; what were the maternity/paternity medical leave benefits?

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I try to treat my cases not as isolated situations but rather with a view to a wider set of social problems with relevance for both men and women. I also lobby at legislative sessions when adoptive and foster care issues are discussed. As a frontline worker with these issues, I believe the lawmakers need to hear my perspective. I try to go with at least one or two colleagues and sometimes network ahead of time with other like-minded professionals such as academics and lawyers to build a stronger base of influence. Policy practice is very important to me on a personal level as well. The fact that my wife and I could legally marry is an example of enormous policy changes in a number of U.S. states. She and I worked hard over the years for legalizing gay marriage but there is still much more to do. And it’s not solely the LGBT community that suffers. Policy has not kept pace with the rapid changes in family life. I have had clients, gay and straight, in long-term relationships but not in a legal marriage becoming trapped in horrific situations involving child custody. Some involved the death of the female who had the child through IVF. Without a clear will, one young child got placed in protective custody and another was sent to live with the family of the woman who died rather than the remaining partner who cared for and loved the child (and whom the child knew and loved). The last comments by Brenda are compellingly relevant to the need for policy practice. While the United States has made enormous strides in gay rights during the second decade of the 21st century, many barriers remain. As of February 2014, there are 17 U.S. states along with the District of Columbia allowing same-sex unions, a figure continually shifting (this is an increase from 9 states just one year before); and some officials are not supporting their state bans on same sex marriages (Trip, 2014). Canada was one of the early nations to recognize same sex marriage in 2005. As of January 2014, with laws passed by Britain and Wales, a total of 16 nations have legalized gay marriage. Note how critical it was for Brenda to have knowledge of state laws and regulations while also

appreciating the unique needs of the Millers. She navigated the potentially competing interests of the various settings, the couple seeking children, and those unknown children. Brenda also contributed to policy making by providing to legislators her perspective as a direct service practitioner. We will return to Brenda and the Millers later in this chapter when we consider community supports and resources and again in chapter 7 to examine how Brenda draws from knowledge of the bioethical issues in assisted reproduction including multiple births, health threats to mothers and fetuses, and the high medical expenses.

Community Practice The concept of community, with its many meanings, is highly complex. It can refer to one’s immediate neighborhood or where one grew up, a large association to which people belong such as a religious congregation, or a felt connection to a larger association such as a political party or Facebook. Toennies’ (1887) seminal work, Gemeinschaft und Gesellschaft, was the first to point to the human need for both “community” and “society.” Drucker (2002) points out that the focus today is no longer on “traditional” rural communities but rather on contemporary urban communities that need input from the nongovernmental, nonprofit sector to enable civic participation and innovation. A study by Liechty (2008) demonstrates the powerful impact by community on individual development and urges a renewed emphasis on “self-in-community” in social work theory and practice. In this book, we rely on the definition offered by Hardcastle et al. (2011)—a social unit with one or more of the following dimensions: exists in a space that functions and sustains needs; has patterns of interaction; offers symbolic collective identification. These authors point out that community provides resources, shapes norms, and affects the ways its members make sense of the world. Fellin (2001) explains that community “has the ability to respond to the wide range of member needs and solve

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its problems and challenges of daily living” (p. 70). According to Warren’s (1978) seminal definition, the geographic boundary is not as important as the social functions including production–distribution–consumption, socialization, social control and participation, and mutual support. Communities are now local, global, and virtual. Community practice includes organizing and development to increase the community’s nurturing capacities, social planning to facilitate the development and coordination of services, and social action to seek redistribution of resources and power. Foster-Fishman et al. (2006) explain that “community building efforts seek to impact significant social issues by focusing on the economic, social and physical transformation of a geographically bounded area” (p. 143). Powell and Geoghegan (2005) agree in their call for a return by social work to its roots in community development and engagement and urge that social work get away from the social capital paradigm and instead return to a community-based view that promotes citizenship. “Community offers the possibility of ‘we’ as opposed to the ‘me—myself alone versus ourselves together.’ This makes it a very seductive philosophy that attracts support from across the political spectrum” (Powell & Geoghegan, 2005, p. 139). Boehm and Cohen (2013) also believe in the importance of community practice and raise concerns about social work students’ lack of interest in this integral component of the profession. They argue for greater student access to personal and political experiences in field placements that build self efficacy. The enormous changes in communities, within the United States and globally, place demands on social workers for a global consciousness in order to address issues of inclusion/exclusion and unequal access to and availability of resources. Increasing privatization and contracting of services in the United States further challenge communities already struggling to manage and strengthen themselves.

Nevertheless, distances inherent in a global society make issues of inclusion and exclusion more difficult, further straining the capacity for caring about social justice and well-being. Groups, communities, and nations communicate whom they care about by whom they exclude from their membership. From a feminist perspective, Tronto (2010) argues for a different paradigm, an ethic of care, to develop a moral sense that allows us to care for people outside our own groups and to develop caring institutions. Mutual and Social Supports Communities are large social systems that include a vast array of interrelated subsystems, many of which are not rationally organized, and continually affect each other and their members. Participation in these subsystems is critical to democratic societies by providing engagement in the civic life, thereby increasing members’ sense of belonging and greater socialization. Hardcastle et al. (2011) argue that such cohesion requires a balance of rights, benefits, and responsibility. In other words, members may expect a range of supports to meet their needs including such things as safety, recreation, education, employment, transportation, and access to goods and services; this may involve advice, feedback, and specific help both concrete and emotional. In turn, the civic participation of members builds community cohesion, increases inclusion, and reduces exclusion. Responsible social participation of members creates networks and social bonding within the community. The mutual support or social welfare function “is the community’s provision of help to its members when their individual and family needs are not met through family and personal resources,” yet as these authors point out, such reliance on the state without cohesion will usually increase the need for social control (Hardcastle et al., 2011, p. 115). Although social support is a critical component of social work knowledge and skills, similar to the term community it is used broadly, and the provision and receipt of support may

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engender different meanings. Some researchers have found that the perception of support alone may have positive effects irrespective of the actual support (Hardcastle et al., 2011), and others point to positive correlations with improved school performance (Rosenfeld, Richman, & Bowen, 2000). In his seminal work on social supports, Specht (1986) explains this complex term as the formal and informal relationships among kin, friends, and colleagues, enriched by broad memberships and participation in voluntary associations. Social networks are the specific set of interrelated people, agencies, and a range of institutions that are the structures for social exchange. Pinto (2006) argues that because “mentally ill people have fewer supports than the general population,” social workers must consider assisting with a restructuring of these clients’ social networks by assessing density and increasing strength and reciprocity (p. 89). As an example, for a woman with schizophrenia, he analyzes her social network, including network size and density, network multiplexity, network reciprocity, and strength of network ties, and uses this information to help determine the intervention approach (Pinto, 2006). The substance of the support and the process of interaction in the networks determine the exchanges—what providers and recipients owe each other. Belief by both that the exchange is fair creates reciprocity, important for cohesion and a high perception of received social support. The objective in social work is to help individuals make the best use of internal and external resources and to enrich the community’s availability of resources to help solve problems: The individual and the community should be in a better position as a result of the exchange (Hardcastle, Powers, & Wenocur, 2004; Lincoln, 2000; Specht, 1986). Cultural and geographic context may affect the meaning and perception of social supports. Wong (2007), for example, points to the strong influence of informal networks in

Chinese culture and the potential need to work with these significant individuals (including caregivers and extended family members) to improve mental health care. In this study, social workers were a critical component in the formal network of help-seeking for the caregivers. A study by Asai and Kameoka (2005) provides further evidence for such global consciousness in its examination of the impact of Japanese sekentei on underutilization of social services for caregivers. Sekentei values interdependence with group interests overriding those of individuals and raises concerns that receiving care-giving help is socially unacceptable. Yet interventions by social service agencies and providers can promote service utilization by policy advocacy to change policies, norms and practices to alter these perceptions. For example, Snyder, May, Zulcic, and Gabbard (2005) examine the importance of working in partnership with the indigenous communities when planning interventions for asylum seekers in the asylum country. Hancock (2005) points to the need for in-service training to increase social workers’ attention to community social supports in the provision of services for Mexican families in the rural southeastern United States. In her review, stronger supports correlated with lower teen pregnancies, improved educational outcomes, and increased family resilience. Corcoran and Nichols-Casebolt (2004) agree that strengths in some of the social environment can offset risks in other areas of the clients’ social world. Sangalang and Gee caution social workers “that individuals can have both positive and negative interactions with members of their social network” requiring attention to these potential stress factors (2012, pp. 57–58). We have examined practice with communities from a foundational perspective; readers would be well served by additional texts such as Hardcastle et al. (2011) and Reisch and Lowe (2000). Tensions for this arm of social work include continuing attention to the needs of

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individuals while maintaining a primary focus on larger community changes. Community practice encompasses organizing, development, and planning to facilitate inclusion and availability of resources and to reduce exclusion and unequal access to resources. Social supports encourage civic engagement enhancing belonging, caring, reciprocity and cohesion; thereby reducing the need for social control. Communities help shape societal norms and socialize the world view of its members. Attention to the social environment is a core component of what the profession stands for and is required of all social workers. CASE STUDY: BRENDA AND ADOPTIONS— COMMUNITY SUPPORTS AND GLOBAL CONSCIOUSNESS

We return to the Millers and Brenda to consider community issues. The large city in which Brenda works, while very diverse as a whole, has strong neighborhood affiliations. Although residents in the immediate area of the Millers are primarily professionals in the upper middle income bracket, some black and more white, it was important for the Millers to consider specific community issues relevant to having a child in their home. One of the issues I explored with the Millers was their social supports. I asked them to identify their social interactions with family, friends, and neighbors and to make particular note of the specific individuals and agencies with which they interacted. I also asked them to describe their community including its safety, public transportation, public schools, grocery stores, libraries, and cultural and recreational activities and to discuss what they liked and disliked. Within the context of these discussions, we then talked about this community’s capacities to meet their current needs for support and considered its potential gaps and strengths once they had a child and its capacity to support a child with special needs or a child adopted from

another country. I asked them to imagine what it might be like for an adopted child from Korea or Kenya (countries they were considering for adoption) to go to the schools in their community or the availability of community services for a child with developmental problems. Building on my own global consciousness, I encouraged the Millers actively to engage with community leaders and groups including schools and athletic clubs to help build tolerance and sensitivity to people from different geographic locales. As part of my community outreach, I offer a class as part of the high school’s adult education programming focused on reproductive rights. There is lots of misinformation, and those of us in the field have some responsibility to help inform the community. I also run a teen group once a week with a focus on building greater supports and inclusion across the different ethnic groups (black, white, and recent increases in Latino and Asian). Note Brenda’s attention to the community’s mutual and social supports and how she considered with the Millers the kinds of community resources they needed and how these might change with a child. Also critical is how Brenda defines her practice as inclusive of individuals, families, and community. She stays informed about contemporary literature on adoptions and found the research by Korff and Grotevant (2011) about the importance of family communications particularly relevant.

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CASE STUDY: TERESA AND STEWART— COMMUNITY-BASED CARE, GLOBAL CONSCIOUSNESS

An organization located in the United Kingdom focuses on the needs of individuals with mental health problems. Teresa, the project manager, discusses the importance of community supports that allow this population to reside in houses located

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throughout the city, rather than having to live in institutions. (Teresa’s practice is also discussed in chapters 3–6.) One particular resident, Stewart, in his late forties, is an example of what is so valuable about our approach. When I first met him at the project just over 7 years ago, he lived in a house that he shared with another person: Stewart was adamant that he couldn’t live on his own. Very psychotic, very paranoid, chronically anxious, his self-esteem was nonexistent. He was overweight, overly hairy, didn’t get his hair cut, beard trimmed, or anything, he had nicotine-stained fingers, his clothes were filthy and secondhand, they probably didn’t fit properly, and he spent most of his life cowering in our kitchen at the office, smoking fags, being really scared. Some of that was because he shared his house with another service user that was equally psychotic and kept bad company, shall we say, and they all were shooting up as far as I can tell. Mind you, they were also on psychotropic drugs. He was very scared by all this, and eventually he said, “I can’t live like this and I can’t live alone and my family won’t have me.” Well after a while, he had to go back into hospital care and then get some help with his addictions, which he had since his twenties. Well, after a while he seemed finally off those illegals and doing pretty well just with his prescriptions. I then advocated for him with the local housing authority to move into one of our community spots—nice houses, they are. Rent is paid separately by a housing benefit. He’s been in this place, got his own room, for 5 years now. We’ve done a lot of work before with this neighborhood—have about four of these houses spread around with four to six guys to a house. The people in the community know us and trust that the people we’re going to put there are going to be okay and that we’ll come right out if there is any trouble. We work closely with the coppers so they can keep an eye as well. This was probably the bigger challenge than the addictions—unless we have a fit place for these folks to live, they don’t stand a chance.

Stewart volunteers now at a day center for people with learning disabilities; he’s a musician so plays his guitar and makes other people happy. I mean the turning point was the flat itself, but the consistency has been support being offered that is relevant to him. People in the neighborhood know and accept him. A van takes our members to the grocery store once a week, and they’re in walking distance from shops for small errands, haircuts, that sort of thing. They share expenses through the welfare monies they receive. Now he’s a very active member in his local church; his faith is extremely important to him and he’d kind of lost sight of that. His self-esteem was such that he felt he wasn’t worthy, whereas now he’s actually so content with who he is as a person and where he is and where he’s come from that other service users find him arrogant because he’ll say, “Well, I don’t do that anymore.” He’s literally just so joyful that he’s not in that place anymore, he’s a truly incredible guy, really inspirational. Members come from many different countries (United States, India, Greece, Italy) and from places in the United Kingdom such as Wales and Scotland, though most were born here in England. At first I thought I needed to know everything about their cultural backgrounds, but in this global society the place of their birth and where they have lived are far more important. For some, their ethnicity and skin color hold very little meaning. I can’t assume anything just by facial features. This case illustrates the extraordinary power of building strong communities both for strengthening inclusion and tolerance within the community itself and strengthening human dignity and respect and a sense of identity and belonging for the community members. Moreover, these community supports can reduce social problems such as substance abuse, decrease costs by replacing large institutions with community-based settings, and enrich lives by contributions to the community from those benefiting from services—the reciprocity and responsibility discussed earlier. We also see from Teresa’s

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work that an enhanced civic life by socialization reduces the need to rely on external social control over Stewart. We also learn a global consciousness perspective by Teresa’s ending remarks; that is, we have to let clients teach us about themselves and not assume we know their culture by how they appear.

Practice With Organizations Similar to policies and communities, organizations change over time to reflect shifts in populations, problems, and technology. One of the most important factors in successful social work practice is the social worker’s capacity both to understand the workings of the agency and to improve its functioning. The employment setting determines the purpose of the practice and the roles and tasks performed by the worker. The term social services originated from socially sponsored agencies providing help, or “services.” Because much of social work addresses general health and illness, its practitioners work primarily through organizations, large or small, public or private, for-profit and nonprofit. As McAuliffe (2012) states, “Social work practice generally takes place within the context of some type of organisational structure” (p. 148). Even with the increase in private practice and proprietary social work, the vast majority of U.S. social workers are employed in human service organizations (HSOs), and this is even more so in the United Kingdom, with most social workers employed by the government in statutory work. While these settings have traditionally employed social workers and teachers, there has been an increase in the numbers of physicians and lawyers. This is partly a result of the increased use of technology and need for specialization. Physicians need the resources of large hospitals that can sustain the costs of expensive equipment and staffing. Similarly, law firms employ large numbers of support staff to help investigate and research case law and precedent. At the same time, in

for-profit settings, professionals are increasingly entrepreneurial. Even social workers in private practice cannot work in isolation from human service organizations. An individual may become depressed or suicidal and in need of the services of inpatient treatment provided through a psychiatric hospital. Family therapy may uncover a child facing abuse, and the weight of the state may be needed for removal from the home and placement in foster care, a process that requires work with the organization responsible for child welfare services. It would be difficult for social workers to provide services to adolescents without coordinating their services with the school and other organizations involved in their clients’ lives or to the elderly without linkages to hospitals and medical care. Healy (2012) points to the need for workers to attend to ethical decision making, which is made especially challenging by conflicting regulations among nation-states. She encourages a human rights perspective by drawing from United Nations (UN) decisions, such as the Convention on Rights of the Child (1990) and Convention on Elimination of All Forms of Discrimination Against Women (1980). The growth of nongovernmental organizations (NGOs) adds to the challenges for global practice with different rules to address similar problems and dilemmas of loyalty and ethics. The UN named these voluntary organizations, formed by people interested in particular problems including climate change, human rights, and a plethora of social issues. Some of the organizations may have linkages with governments, but members do not represent a government or political party. As we examine the organization as a social system, we cover a range of topics including auspices, collaboration and teamwork, case management, linkages between organizations and communities, and leadership as areas of knowledge essential to provide effective services through the organization.

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Social Work Role, Identity, and Divided Loyalties In addition to the role of practitioner delivering the organization’s services, social workers may also perform the roles of manager, team leader, executive director, trainer, consultant, or coordinator of services, among others; shifts in identity often accompany such different roles. These role transitions are further complicated by the inherent complexity in the dual roles of organization employee and member of a profession with the potential for conflict between agency services and professional ethics. Acknowledgment of their multiple roles is necessary for social workers to consider ways to balance them while seeking to improve service delivery to meet the needs of individuals and communities better. Identifying one’s perspective as either local (greater commitment to the organization and its particular service niche) or cosmopolitan (orientation toward the profession’s breadth) allows for increased awareness and rational decision making in enacting these different orientations. Academics share these challenges when their roles as educators conflict with their identity as social workers (Bisman, 1985). Membership in a range of settings and groups that reflect both a more narrow agency or population focus (such as child welfare) and the broader issues of social work (such as NASW or IFSW), and participation in educational workshops that represent a wide range of professional issues can offer information and support to help manage the many claims on loyalty. Auspices Human service organizations (HSOs) fall under three auspices. Public are government formed with officers appointed by elected officials, supported by tax revenues. Accountable to the public at large to serve a wide range of social issues (health, education, welfare), and as such are responsive to political pressures. Voluntary not-for-profit HSOs provide service to particular

populations (education, faith-based, charitable) with a mission of service to that community not to the government; they enrich civic life by volunteerism and targeting services to a plurality of groups (elderly, civil rights, immigrant populations, etc.). Funded by various philanthropic groups with vested interests, they have tax exempt status under charitable laws, and as not-for-profit, monies after covering expenses are reinvested to improve the organization’s services. Proprietary for-profit are privately owned with the mission to gain profit, they pay taxes, have shareholders and depending on the size may have a board of directors. Responsive to market forces, they tend to be more flexible and welcoming of clients who can pay for services. (Hardcastle et al., 2011; italics added)

In the United States, social work settings are increasingly nongovernmental; it is essential to know from where and whom these agencies receive funding, as the source affects the kinds of services offered and the role of the professional. More than half of social work services is contracted out to proprietary forprofit and nonprofit secular and sectarian agencies. Such shrinking government support indicates lack of a shared community commitment to the welfare and threatens the profession’s long-term viability. Those in public agencies face greater challenges as they serve ever poorer populations with severe problems, increasing income disparities, and more clients competing for decreasing services. At the same time, in many poor nations with few resources, NGOs have provided leadership in serving vulnerable populations. So the issue is not whether the setting is profit driven, but whether the profit is used for providing services to enhance the public good (Hardcastle et al., 2011). Teamwork and Interdisciplinary Collaboration Practice from within an organization involves teamwork and interdisciplinary collaboration,

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referrals, and networking/coordinating. Technological developments and increasing social complexity require organizations to interact with each other. To provide services to help their clients, social workers spend a good deal of time communicating with other professionals and agency staff. Through a range of approaches, collaboration involves coordination with colleagues in their settings and at a range of other agencies. Bronstein (2003) points out that interdisciplinary collaboration between social workers and other professionals requires interdependence, professional activities created for this service, flexibility, shared goals, and a process of reflection. Outside influences necessary to facilitate effective collaboration include administrative support, commitment to the agency and profession, and relationship dynamics. Claiborne and Lawson (2005) agree that this kind of work poses special challenges, based as it is on changes by professionals in what they ordinarily do and in the settings where they work. These authors offer a logic intervention model that emphasizes developmental progression including benchmarks and outcome measures. Though necessary for effective practice, the process of building collaborative relationships is not always smooth or easy and is even more challenging when involving multiple disciplines. D’Amour and Oandasan (2005) define interprofessional care as “the development of a cohesive practice between professionals from different disciplines . . . it involves continuous interaction and knowledge sharing between professionals . . . seeking to optimize the patient’s participation (p. 9). In her study of the experiences of patients, Shaw (2008) found that patients were positive about their participation explicit in this model and supported greater patient involvement in the planning and structure of services. Drawing from a feminist perspective, Bergen, Edleson, and Renzetti (2005) present evidence of improved services to women in violent situations from interagency collaboration. These

services include improved shelters providing therapy and prevention and collaboration with police, courts, hospitals, and schools. Chuang and Wells (2010) also explore interagency collaboration in child welfare, finding that youth receiving services from a single agency were more likely to receive greater attention and care including both inpatient and outpatient behavioral health services. Cooper, Anaf, and Bowden (2008) advocate the creation of formal and informal collaborative efforts that recognize and honor the competing values, ethics, and objectives of each profession (pp. 305–306). They describe a fascinating collaboration between social workers and the police in working with Bikie-gangs, “a colloquial Australian term for outlaw motorcycle clubs/gangs involved in violence and organized crime, murder, abduction, assault, torture, illicit drug manufacture and trafficking, illegal firearms possession and trafficking, prostitution, money laundering, fraud and links to security protection” (p. 308). In his important historical and philosophical overview of social work, Siporin (1975) compares teamwork to the “committees of paid charity workers, volunteers, and friendly visitors who once provided direct services in the charity organization societies, settlement houses, and public welfare agencies” (p. 186). In some agencies, the team meets only for intake purposes or for general administrative needs; in others, it is responsible for client treatment planning. Hardcastle et al. (2004) define a team as “a number of people working together, with each member or position on the team having a fairly unique, complementary, and essential contribution that forms a whole necessary to achieve the common and shared goal” (p. 274). While the ideal concept of the team focuses on equality among members and the unique expertise of each, the reality is often quite different. A range of skill sets, areas of expertise, and a hierarchy of authority are usually present in most human service teams, which often consist of social workers along with psychologists,

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nurses and nursing aides, psychiatrists, and other medical doctors. Payne (2000) explains that success for teams is collective: Individuals do a job well only when the team succeeds at its goals. Whether or not teams serve as linchpins in bringing together different agencies, they must formulate strategies for drawing from the expertise of each member and develop clarity around roles and accountability. Clarity of tasks can help the team maintain a focus on goals and objectives and facilitate effective contributions from each member regardless of status. Morrison (2007) explains that social work is a “. . . collaborative practice. It is not enough for social workers to be able to work individually with their service users, if they are unable to make and sustain constructive changes within and outside their organizations” (p. 257). Within a collaborative framework, the concepts of resonance and dissonance are crucial. Resonance “occurs when two people’s moods align around positive feelings which create optimism, mental efficiency, fairness and generosity. In contrast, dissonance occurs when one person is out of touch with the feelings of another, putting that person offbalance and on-guard. Just as resonance is part of what makes work meaningful, dissonance leads to defensive pre-occupation, inefficiency and poor decision making” (Morrison, 2007, p. 257). Research results indicate that better interagency collaboration and good use of interdisciplinary teamwork leads to better outcomes. To contribute the important social justice and human well-being perspective to organizational services, social workers must have and exhibit a strong commitment to their professional identity (Chuang & Wells, 2010; Dewees, 2004; King & Ross, 2004; Supiano & Berry, 2013). Case Management Social workers often deal with clients who have a multitude of problems, and several agencies work with the client at the same time. Through coordination, the social worker helps

to integrate services, performing a pivotal role in clarifying the function of each agency, helping prevent duplication of services, and keeping focus on the identified problems. Case management is a function and role that addresses the dual concerns of coordination of services and cost-effectiveness and should result in services appropriate to client needs that are not wasteful of funds. Case management activities grew in the 1990s as a process intended to ensure that clients of human services systems receive the care and opportunities to which they are entitled. (Both the settlement houses and the COS had concerns with coordination including community development projects, documentation of services, and the development of efficient interagency cooperation.) In addition to its coordination activities, case management may also involve clinical interventions. Ferry and Abramson (2005) remind us that individuals receiving case management services may also present with psychosocial problems that need attention. These may result from emotional reactions to the need for longterm care, financial problems, or elder abuse, among many others (Ferry & Abramson, 2005). Again we see that attention to person in environment is paramount. Hall, Carswell, Walsh, Huber, and Jampoler (2002) use the Iowa program as an exemplar for providing innovative casework services to those needing case management. Buck and Alexander’s (2005) research on client perspectives supports these findings. In their research, they discovered that clients gave high ratings to services that included both instrumental and affective support; concrete services were especially valued. In the United States, case manager has increasingly become the term used for those providing child protective services. Until recently, the case manager role was one of the many roles performed by social workers. The contemporary generic use of this title obfuscates professional affiliation. It is not unusual for settings to hire case managers who are recent college graduates with no social work background or education,

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which can relegate services for this vulnerable population to providers with no expertise; we all hear of the very public failures when children are harmed or killed by their parents while under child welfare supervision. Guransky, Harvey, and Kennedy (2003) address the ethical challenges in case management in their argument that for competent and ethical practice, “social workers must act on their responsibility to inform clients about the service restrictions they will encounter,” despite potential discomfort in upsetting the client. This will facilitate realistic goal setting and client expectations. At the same time, good case management requires that policy concerns be raised within the organization to ensure clear practice guidelines (cf. the earlier discussion of divided loyalties). Linkages Between Organizations and Communities Social workers have a responsibility to ensure that the setting draws from its mission to guide services and that these services are relevant to the needs of individuals and to the broader community. In order to build direct linkages between the needs presented by individuals and the needs and resources of the community social workers must consider problems and policies in the larger society. For example, Altshuler (2003) believes that policy changes that require sharing of information could help to improve collaboration between child welfare workers and the public schools, and that cross training for both the teachers and caseworkers and proactive planning could ameliorate particular situations for a family and a school and also help to prevent future problems by outreach to the broader community. Powers, Bowen, and Rose (2005) are also interested in improving school success and advocate using the social environment to identify intervention strategies. Hardcastle et al. (2011) explain the organizational domain as the territory identified in relation to the social problems, populations, and services the organization addresses. The

domain is not exclusive to one setting but is shared by a larger group of organizations. These authors call this broad network a task environment; domain consensus is when the various settings have reached a satisfactory working agreement among themselves about boundaries and shared expectations. Such consensus is critical to ensure that organizations effectively serve their communities with coordination and wise use of resources (Hardcastle et al., 2011). Assertiveness and Leadership Familiarity by social workers with the profession’s multiple levels of practice provides excellent preparation for leadership roles in teams. Social workers sometimes function as covert leaders or emerge naturally in other situations as the acknowledged people to facilitate meetings and ensure the decision making necessary for good teamwork (Payne, 2000). Social workers can be instrumental in providing focus and direction to the work of the team while also providing emotional support to team members in follow-through on planned activities. Hardcastle et al. (2004) point out that conflict is inherent in the change mandate of social work, and competent practice therefore requires dealing with conflict directly and confidently: “Human service professionals must be able to communicate forcefully with clients and other providers, advocate their point of view, and obtain what they need from authorities” (p. 223)—simple declarative sentences are often the most useful. They see assertiveness as a “tool” of practice to command personal power and assert human rights; model assertiveness for clients; and advocate in interpersonal, organizational, and community situations. Several authors specifically address issues around ethical practice within the organization including Reisch and Lowe (2000), Hyde (2012), Chernesky (2005) and Kirst-Ashman and Hull (2001). Growing forms of social work include management, administration, and entrepreneurship bring additional ethical dilemmas that involve maintaining focus on

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the multiple levels of social work practice, balancing one’s loyalty to the agency with ensuring that the agency is meeting its mission and client needs, and weighing budgetary issues with community needs. Carnochan and Austin (2001) believe that organizational change often requires changes in the organizational culture. In these situations, wise leadership articulates the problem areas, the resistance to changes, and change strategies, which may include the use of teams and participatory management. In this discussion, we have explored foundational issues, further resources include Hasenfeld, 2010; Hardcastle et al., 2011; White, 2010. We next consider some cases that illustrate the complexity of being an employee in an organization while providing social work services to clients. Responsible for attending to their organization’s responsiveness to client needs and to its overall quality of service delivery, social workers often find it necessary to work toward change within the organization itself. Social workers are responsible for attending to the service delivery of their employing organization to ensure that it meets the profession’s ethical standards toward the promotion of social justice and human well-being. This requires awareness of funding sources (auspices), skills to collaborate and engage in teamwork with other disciplines and other settings, knowledge of case management approaches for coordination of care, focus on the needs of both individuals and communities served by the agency, consideration of possible policy practice to help modify organizational practices, and use of assertiveness to build leadership expertise for ethical practice. CASE STUDY: ELLEN AND JANE—SOCIAL WORK ROLE IN THE ORGANIZATION, IDENTITY, AND LOYALTY

We will examine the practice of Ellen (now in her forties) with Jane through several chapters in this book. Here, Ellen reflects back on her field placement in outpatient psychiatry at a large Veteran’s

Administration (VA) hospital in a midwestern U.S. city that employed many different professionals, forcing her to work hard to develop a social work identity as she struggled to distinguish her role from that of the psychologist and psychiatrist, the occupational therapist, and the nurse clinician. She further had to make sense of potentially conflicting loyalties between the VA hospital and the social work profession. (Case material here is a composite from a case discussed in Bisman, 1994. Ellen’s practice is also discussed in chapters 3, 4, 6, 7, and 8.) Many jobs and clients over these years offer me a wonderful historical perspective on my first months as a master’s of social work student and then as an employee. It was easier at first to clarify what social work was not and much harder to determine what it was. The nurses seemed very involved in handling medication, maintaining client records, and supervising the nursing aide; occupational therapists handled activities and exercises with the patients. Therapy was offered by the psychologists and psychiatrists; the psychologists also tested patients and the psychiatrists diagnosed and prescribed medication. Social workers seemed to do some of all these things, but how were we different and how the same? After the first few months I began to see that the other staff turned to me for family background history and information about the patient’s current social situation. I was the one who brought in a historical perspective on earlier social functioning (education, employment background, interpersonal relationships) and provided an update on current functioning (living arrangements, job and finances, social contacts). My first job was at the same VA where I had my field placement. It wasn’t until I had been an employee for about a year that I realized I had two roles at the hospital. I was a member of the Department of Social Work and an employee of the VA hospital. Although the pay and benefits were good, it was not being a federal civil servant that was important to me, but rather being part of the social work profession. I joined NASW; attended local, state, and national social work

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conferences; and read social work journals. I think working in a multidisciplinary setting was good in pushing me to sort through how my professional role and expertise were distinct from the other professional occupations. I also developed more respect for my own profession. I saw myself as a social worker providing services to clients, and the VA was the vehicle through which to do that. When I worked on inpatient units, the hospital environment was truly the patient’s community, and I worked very hard at making that community a positive one for the patients. Person in environment made so much sense to me in classes, and it was exciting now to see its relevance no matter the specific issues facing each of my clients. Ellen has touched on many of the important issues discussed in the literature about role theory and professionals in organizations (Guba & Lincoln, 1994). The expectations of others for Ellen’s role as a social worker helped her clarify the expectations she had for herself. Using Gouldner’s (1957) seminal typology, Ellen would be considered a cosmopolitan. Relying on outer referent groups, she was highly committed to the development of her professional social work skills and did not define her work by her VA employment but rather saw the employment as a means of accomplishing her mission of service to her clients. Her professional rather than a bureaucratic orientation allowed her to address ongoing matters in the organization for improved client services.

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CASE NARRATIVE: BRENT AND THE KIRK FAMILY—INTERDISCIPLINARY COLLABORATION, GLOBAL CONSCIOUSNESS

We will hear from Brent later in this chapter when he discusses his work with the team as a group work process; the setting is a specialized program in the United Kingdom for children at risk. Here he emphasizes networking and coordinating in provision of

an array of complex services to these multiproblem families. To ensure safety and facilitate the Kirk family staying together, Brent discusses his approach with the different disciplines and settings. The Kirks have two kids in the program— 9 months to 4 years—at that age statutory nursery kicks in anyway. They get valuable resources and support. I worked locally in the city in a child protection long-term work team, and my dream came true in doing preventative work in Sure Start. It’s very loosely built on the 1960s Head Start of the United States. Only it takes a lot more energy in putting resources into families and starting almost prebirth with our good U.K. prenatal care. And Head Start just was coming on stream when I was in my second year post-qualifying, so it was perfect because in working in the city office, I built up a professional network. I’ve been there 5½ years, but it’s in a team of now 40-plus, not 40 whole-term equivalents but that number of people, a multiagency team, working in a project that was designed to work very closely with families in areas of disadvantage and deprivation. So I’ve got a lot of experience and knowledge, and I start off with respect by my team, who welcome my leadership. This makes my work much easier. All schools have to have a child protection lead within the school, one member of staff who has sole responsibility for issues of child protection, so any child protection concerns within the school would be consulted with the lead within the school, but because I work closely with the schools, there is a kind of very informal “I need to talk to you about this child, I’m a bit concerned.” And that’s one of the reasons why it was fantastic that I did my 2 years postqualifying within this busy authority social-work team, because I know how the system works and I understand about threshold criteria. And this is how I helped my family. Each model of Sure Start has grown differently depending on the lead partner within the growth of the project. We were clear that we didn’t want our Sure Start to be seen in any way, shape, or

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form as a statutory agency because we recognized that many of the families living in the very areas that we were targeting were the classic sort of hard to reach, difficult to engage; that we felt that if we looked like or felt like a statutory agency, we wouldn’t be able to reach them in a supportive way and so—but not all Sure Starts did it in that way, some very much employ social workers via the local authority and keep very much with a statutory role. Mine’s not like that, and I very much believe that the kind of creative and informal way we are able to support families is very effective in terms of the number of families we’ve supported, and we’ve managed to minimize the occasions when we’ve actually had to make a referral to protective services. It has been very impressive actually, I mean in 5 years, I’m not sure of the current, precise figure but in 5½ years, they have referred more than 60 families to me and my service, and in the same period I’ve only had to refer something like 17 back, only two or three of those were ones that they originally sent to me and I tried to support them, but despite the support we gave them, we weren’t able to turn them around. I was able to help the Kirks become stable. Both parents have jobs, the mother Carol is a cook in the school that the kids attend—they leave together in the morning. Carol and the father, Cliff, have increased self-respect and feel empowered to raise their kids and function as a family without using violence on each other. Their functioning as a system before the kids were placed in Sure Start was almost nonexistent—no structure, no rules, no one in charge except the blustery, angry Cliff, who took his frustrations out on Carol. She was in a subservient role with no say over anything. What she now earns is equivalent to his income in construction and he’s thrilled with the financial stability. I make it a point to follow development of these programs in other nations; we all have a lot to learn from each other. The Scandinavian nations are especially good at providing early schooling for their kids; of course, they have far

less poverty with their economic policies providing a more developed social safety network. A reflexive and sensitive social worker, Brent needed to spend an enormous amount of time and patience on communicating with other professionals on his team and directly with the school setting. He showed flexibility yet always remained focused on the goals of safety and building family strengths— a multidisciplinary early education program for the children provided aid and structure for their entire family, ended the family violence, and created more equality between the mother and father. Brent had to teach the social work and systems perspective to his multidisciplinary team while applying these ideas to his direct practice with the Kirks. His global perspective is evident in his knowledge about preschooling approaches in other nations, which he draws from for information about ways to improve his program’s services.

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CASE STUDY: MARIA—OUTPATIENT/INPATIENT COLLABORATION, ASSERTIVENESS, AND LEADERSHIP

In this case, we explore collaborative activities and the conflicting demands and loyalties discussed earlier. Maria is a 34-year-old Latina inpatient social worker with a university hospital in the United States; she is seeking the collaboration necessary between inpatient and outpatient staff for successful discharges. My primary task is to assist in the development of community group homes with structured medical follow-up care. During a serious economic downturn, other inpatient staff members were getting anxious about losing their jobs, and I found myself increasingly alone and unsupported in seeking discharge planning. Although our policies and job responsibilities included early discharge of patients into the community, the other social workers, physicians, and nursing staff were

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pushing for continued inpatient care to help the hospital make more money. Loyalty to my setting has me wanting the hospital to continue to thrive, yet superseding this is loyalty to my profession and what it stands for. So now I felt totally stuck. There were always challenges in getting the outpatient folks to work closely with these patients immediately after discharge when they are particularly vulnerable to rehospitalizations. I didn’t know how I could manage to pressure both of these staffs to “do their job.” Even though I didn’t have primary supervisory responsibility over either group, I did feel responsible to “make things right,” and I was the senior staff person. Such a feeling of obligation comes from the fact that I am here as a social worker, which means creating change of people and environments—helping my individual clients stabilize during inpatient care, ensuring that my setting provides what clients need both in the hospital and then in follow-up care, and that the community services in that environment can meet my clients’ continuing needs. I decided I had to network with colleagues with whom I had already formed collaborative relationships to build awareness and support for doing what was right for our clients. I tried to be assertive with such comments as “We all know the right thing to do here, which is to move our patients as quickly and smoothly as possible to community settings”; “Our discharge rates are public information, retaining more inpatients to potentially bolster hospital finances can backfire on all of us.” After ensuring some support for my position with other staff, I was successful with my supervisor in my request for a special team meeting, which I started off with “I have asked for this special meeting to address recent actions that could be detrimental to our clients, to the long-term health of this hospital, and to the community. Although I know many of us are worried about job losses, lengthening inpatient time can actually increase that likelihood. I suggest we invite the hospital vice-chancellor to talk with us about the hospital finances and job security and agree

to pursue our discharge planning and work with outpatient services.” Note that Maria was assertive in her use of declarative statements, advocated directly for her position on the nature of the problem and on what to do, was the covert leader, built and used her collaborative relationships, and pressed for the values of social work to inform decision making over some short-term financial gains that could cause harm to the clients and the setting. It is easy to marginalize an issue if it appears there is little support; Maria knew not to act on her own, but to enlist the help of others prior to the confrontation. She also had to be informed about facts, history, context, and the views of others; in other words, prepared to explain and defend her position.

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CASE STUDY: MARIA—ORGANIZATIONAL LINKAGE WITH COMMUNITY

Maria contrasts her success above with when she was a second-year master’s student placed in a family services agency in a small U.S. township. Recognizing that many families from the surrounding areas were not accessing services (where the poor and people of color resided), she decided directly to confront the agency director. Not particularly concerned with being liked (a problem for many social workers), Maria took her advocacy role seriously. Wow, I really learned an important lesson from that experience. I went right in and challenged her that we had an obligation to reach out to these other families and suggested setting up additional clinics and adding more evening and weekend hours. Of course, she immediately defended the status quo, claiming they had tried different approaches but “these people” didn’t really want any help, and she couldn’t support the additional expense. I realize now (and even then after presenting this in my practice class) that I did not have enough

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information and should have done more homework. There really were recent policy changes that resulted in heavy cuts in agency funding. I could have strengthened my argument by talking with agency staff to learn if they shared my views. Strategizing with any who agreed with me while also gaining a deeper perspective on the agency’s previous outreach efforts would have been a more thoughtful and effective advocacy for organizational change. We even could have considered ways to generate additional monies.

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CASE STUDY: TERESA—CASE MANAGEMENT WITH STEWART

Here we again visit with Teresa from the United Kingdom, who discusses how she helps ensure that Stewart’s services are integrated and coordinated. There’s always so much to keep track of, for us and the residents. We help fill in the forms and make sure they get the right benefits and things. So yeah, and we’re around if there are legal disputes, we’re around to try and help mediate whatever as well, so he quite likes working with us. Anyway so I said to him, “I actually have a flat, I’d like you to think about it,” and he thought about it and he talked to his key worker and he came back and said, “I’ve decided I’m going to give it a shot,” and I swear the difference in that man from the day he moved into the flat with the other four guys, even though when he moved in he was scared but he was saying to me, “I didn’t think I would ever live alone in tenancy again,” and he was so pleased with himself. Sure he’s needed a bit of help with it, but he needs less now and has sustained living in the community with others. He manages his own bills now, which he never did before, he was chronically in debt; he stopped smoking; he has lost lots of weight; he goes to the barbers regularly; he gets his clothes dry cleaned because he likes to, whether they need it or not; and he budgets for that kind of thing.

Stewart knows we are here for him and that we have some clout. He’ll phone up and ask for our help in managing his daily stuff and in getting his other services such as medications, money, and so forth. We see in Teresa’s work the many tasks she carried out to sustain Stewart in community independent living. To ensure success, she facilitated Stewart’s access to and receipt of services. In addition to helping him find a flat and move, she made sure he would receive the supports necessary including financial, social, and emotional. She not only mediated conflicts between residents but also intervened to help them bond together. Coordination of services was only one of the many functions she performed in her role as a case manager.

Small Groups and Families To seek person in environment changes, social workers may interact with individuals, families, and/or groups; this can occur separately or simultaneously. In the following sections, we touch briefly on practice with groups and families and identify additional sources to provide the necessary depth for practicing with these modalities. In addressing the problems individual clients face with respect to community safety, social workers might meet with small groups of residents, a large community gathering, the extended family of individual clients, as well as each individual client. Related to the agency function, especially in child welfare, it may be necessary to meet with family members in order to provide services to individuals. Moreover, it is probably not possible to provide agency services to individual clients without various team and other staff meetings within one’s discipline and setting as well as across disciplines and settings. Group Work Meeting with residents in groups was central to the settlement movement. Whether providing a substitute family experience, protecting abused women, fighting for child labor laws,

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meeting the basic needs of housing and food, organizing for better wages, or ensuring trash collection, safety, and the right to vote, these settings offered group experiences and support. Addams (1910) referred to Hull House as a place for shared fellowship and development of a civic and social life . Elshtain (2002) points out that Addams “never lost sight of the single, unique person” as she worked to foster lives of purpose, which she did through building a sense of belonging and connection with others, often by group meetings (p. 253). This primarily political orientation continued until 1935 when the National Conference of Social Work formally acknowledged group work as a social work method. By the 1940s, a number of emerging theoretical developments in the growing fields of psychiatry (Freud, 1948) and the social sciences heavily influenced social group work including psychoanalytic theory, sociological ideas (Coyle, 1947; Homans, 1950), and contributions from psychology (Lewin, 1951). Treatment and rehabilitation became linked to group work intervention during the 1960s and 1970s. Yet the ideas of these early group work scholars still have relevance today such as purpose of the group, actions done to achieve the purpose, interactions among members, norms of behavior, relationship with external systems in its environment. In her seminal work on social work and groups Northen emphasizes the importance of the group’s purpose and explains that “it means any ultimate aim . . . goal . . . refers to a specific end that is instrumental to its purpose . . . goals of a group influence the standards by which it will be evaluated, [and] the patterns of communication. (Northen 1969, p. 19)

Contemporarily, social workers use groups within settings for team meetings, in joint meetings with other professionals, and for treatment. According to Hardcastle et al. (2004), group development undergoes several stages and that “until that collection of autonomous individuals begins to feel some allegiance to the collectivity

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and finds some way to work together on a common goal, a group has not yet fully formed” (p. 276, italics in original). Similar to most social interactions, the stages of group formation are not usually linear but may overlap with each other. Much of the collaborative work carried out within and between agencies may occur in working-group meetings for treatment coordination, case consultation, service approaches, budgetary issues, short- and long-term agency goal setting, and resolving problems. For effective meetings that are not a waste of time, it is important to plan ahead so that the group has a clear purpose and agenda to complete a task or for decision making. This often requires good and sensitive leadership by a chairperson who sets expectations that members arrive to conduct business, stays focused on the agenda, allows for participation, mediates conflict where necessary, and sticks to the time frame previously agreed upon (Hardcastle et al., 2011). Social workers will perform various roles within groups, depending on the agency function and purpose of the group meeting. Roles may be formalized, but often are not explicitly stated, which may result in differences between the overt and covert leaders. Despite the stated role of social workers, it may be necessary for the social workers to facilitate the group leadership and process and help to develop cohesion and task focus (the content of the actions). Facilitating a group requires attention to both process and content. Help by the group leader is often necessary in identifying the problem and set of tasks requiring group intervention, potential strategies and the roles of various members. There may well be different goals for each group member that may not always match with the group goals. (Hepworth et al., 2006)

Toseland and Rivas (2001) point out the range of classifications in treatment-oriented groups including support, education, growth, therapy, and socialization. Task groups tend to be more structured and involve less self-disclosure.

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Assignment of roles in these kinds of groups can increase participation and shared decision making and facilitate the group’s success in accomplishing its task (Toseland & Rivas, 2001). Dessel, Rogge, and Garlington (2006) encourage intergroup dialogue to advance advocacy, justice, and social change. Particularly interesting is their use of this approach to decrease divisiveness among social workers across different areas of practice (those focused on individual change and those focused on social reform) and to increase their cooperative efforts toward social justice. Chapter 3 has fuller discussion on advocacy and empowerment. Social workers often refer clients to mutual aid groups. Many of these groups draw from twelve-step programs in which group members share similar problems and provide support for each other. In many of the addiction support groups, following one year of sobriety members may become ‘sponsors’ and agree to be continually available to specific group members. At the same time some mutual aid groups, such as those focusing on grief and trauma, seek professional supports from social workers. Groups can empower individuals dealing with addictions (Ronel and Libman, 2003), trauma (Knight, 2006), sexual abuse (Knight, 2005), dual diagnoses such as severe mental illness and substance abuse (Bogenschultz, 2005), and loss (Orr, 2005), among many other issues. Strengths based, they provide means of social interactions with and without professional interventions. Gitterman and Shulman (2005) point out that members benefit from the multiple relationships as well as the “giving” and “receiving” of help and support. In groups, the modes of behavior deemed acceptable and those that are not may be articulated or remain unstated. It is helpful, however, for social workers in group work to make explicit the specific guidelines for such matters as touching, smoking, attendance, and confidentiality. Groups also need to decide on the mundane matters of frequency, location, and length of meetings. Some groups are open

where members may join at any point in time, while others are closed wherein no new members are added once the group begins meeting. The purpose of the group should guide the format. Open-ended groups offer help with crises and supportive services; they are often used in hospitals and are the regular structure in 12-step programs and mutual aid groups. Closed-ended groups are more the norm for long-term treatment, family therapy, and bereavement. Tensions for those in group work include the choice of this modality over individual or family interventions (some practitioners may use a mixture of all). Providing services via group work is often a good use of resources— less costly for each client and potentially more remunerative for the setting. For some clients, the empowerment and socialization that can occur is a definite advantage for treatment in a group. At the same time, there are other clients who do not want group treatment. Choice of modality will relate to the agency’s structure and purpose and to the assessment/intake process. The following are good sources for group work: Corey and Corey (2002), Reid (2002), and Shulman (2005). Group work has been part of social work from its early roots in the settlement movement and reliance on them by Jane Addams to build caring and belonging and to advocate for community services. Pottick (1988), in an eloquent discussion of Addams’s philanthropic goals, argues that the profession should indeed borrow from Addams’s innovative perspectives for addressing social problems to replace “dominant-culture solutions” that are not working. In contemporary practice social workers organize social action groups to advocate for policy changes and changes within organizations. They are also members and leaders of groups in team meetings; use mutual aid groups as referral sources; and engage in group work practice for support, education, growth, therapy, and socialization, among other functions. As we will see later in this chapter, groups have similarities to families. They

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both are social systems wherein the whole is greater than the sum of its individual members, and each reflects norms of the wider society while also building intrasystem norms. CASE NARRATIVE: TERESA AND GROUP WORK—FOR SUPPORT, EDUCATION, SOCIALIZATION, THERAPY

Following up on Teresa’s practice with Stewart discussed earlier in this chapter, here she discusses her use of group work. We always say to people “Start from here, this is what we’re clear about and we’ll build on that over time as you get to know us and we get to know you,” and you can be saying “Actually I could use some support for this as well,” and we might just say “Actually I’ve noticed, it would be helpful if we did this or you need to do that,” and it builds from there so it always changes. So for me that’s about support and review on a regular basis. This also includes other service users, sometimes they ask each other to go along with one of us, “I want to say this to the doctor but I’m scared to, would you come with me, I’ll feel better if you’re there.” And we all go together. It’s heart-warming to see how these guys come to really care about each other and despite their own serious individual problems learn how to reach out and help one another. We social workers have a clear role, but so do the members; and for many of these guys, they didn’t grow up with these kinds of skills. In a sense, we are reeducating them that it’s okay to care about someone else and that in the process they have a group of people caring about them. The power of a good group is evident in Teresa’s comments about the supportive help and sense of belonging gained by Stewart, who was finally able to live a full life outside of an institution and be of help to others in the community.

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CASE NARRATIVE: BRENT AND INTERDISCIPLINARY TEAM GROUP WORK—CHILD PROTECTION

Here we revisit with Brent as he discusses his group work with the multidisciplinary team. I’m the only person within that huge team from a social work background, and this for me is where often the social work value thing is quite a challenge because those values aren’t embedded in preschool education training or nursing, and I have to educate and even challenge other practitioners in my team because I work with midwives, health visitors, speech language therapists, a whole range of play workers and crèche workers. There’s a huge number of fantastic practitioners, so the wealth of knowledge and experience within that team is immense, and yet I’m the only central point of contact in terms of children of most complex concerns. I am their first port of call for consultancy and as a co-worker if they’re really concerned about the welfare of the child/children and the family in general. I also work very closely with the local primary school. I use all my group work skills and then some in getting everyone aboard as a working group. I start out building a bonding among all of us so that each member has a sense of belonging to this group and that we share a common purpose. In this case, it is to help the Kirks build on their strengths so that they can ensure a safe environment in which their children not only survive but thrive. This shared purpose can help us work as a team despite our different professional orientations and can facilitate treatment coordination. I allow for discussion of the different service approaches, and as the group leader I move the discussion along within the time frame we had set. I’m always surprised at the lack of a clear agenda for meetings—I always make one available at least the day before. And we don’t just talk: I set a time schedule for discussion followed by decision making. Rules include treat each discipline and each group member with respect; and

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effective decisions require confrontation and critique, but never on personal issues, just on the treatment. Brent’s leadership of this interdisciplinary team illustrates the necessity for these meetings to have a clear purpose, an agenda and discussion schedule, as well as time for decision making. We also hear from Brent in chapter 5 on his building relationships.

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CASE NARRATIVE: DONNA AND ESTABLISHING

practice was also compromised because value was placed solely on practice experience and intuition. Nevertheless, we didn’t want to lose the positive contributions of practice wisdom. In our current mutual aid approach to groups, we remain open to newcomers and often have several facilitators including a professional who is the primary group facilitator along with students, interns, and those who have had experience with the problem (this can be addictions, sexual abuse, violence). Our funding has increased with this hybrid model along with our effectiveness.

GROUP BOUNDARIES—SUBSTANCE ABUSE

Drawing from her almost 30 years as a social worker in the southeastern part of the United States, Donna discusses some of the challenges in group work. In the 1960s, group work took a turn toward rehabilitation drawing heavily from individuals who themselves had past experience with the problem to serve as group facilitators. I have worked in such settings including mental health and substance abuse treatment. My role was individual social work services to these clients. In some cases, the mixture was quite effective, and clients benefited from these very different approaches. In other cases, some clients found it confusing to transition from the more formal/professional relationship with me where they were called client to the more egalitarian atmosphere in groups facilitated by those with past histories similar to theirs where they were called consumer. I think now with state regulations professionalizing practice in addictions, we offer a better marriage of the two treatments. Without these guidelines and standards, we had crossing of boundaries where the helping relationships were becoming either friendships or parent/child— neither were empowering or fostering self-determination. Furthermore, no records were kept, impeding our ability to collect insurance and grant funding. Supervision and theory-guided

Donna’s comments point to the value of flexibility and creativity in delivering group work services. The balance she describes of embracing the value of experience combined with professional boundarysetting and knowledge-guided practice can appeal and be helpful to a range of populations.

Practice with Families From its beginnings, social work has focused on families: both the friendly visitors and the settlement workers attended to issues of family life (Nichols & Schwartz, 2004). Moreover, the centrality of family for individuals epitomizes social work’s person in environment perspective—individuals are members of the family system, which in turn is part of a larger societal environment. Environments shape individuals while simultaneously individuals affect their environments. Constable and Lee (2004) refer to the family as “the basic informal welfare system in any society” (p. 9). Through its socialization function, family influences the values and behaviors of its members and provides the lens through which individuals learn about the wider world. Research indicates the important influence parents have on the civic engagement of their children (Kelly, 2006). The well-being of the family in terms of income, housing, education, and safety, among other

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variables, also influences the future well-being of its members. The composition and definition of “family” may vary across and within small communities and large nation-states and will reflect the mores of particular points in time. An example of this is the long struggle to recognize the rights of the LGBT population to marry and their legitimacy as families and the major breakthroughs beginning in 2011 with successful passage of legislation in several U.S. states, and the 2013 Supreme Court ruling that married same-sex couples were entitled to federal benefits. Adoptions for these familes are still difficult, and discrimination continues in many states, yet defining a “normal” family as one consisting of a male and a female no longer applies in many parts of the United States and other nations. Material conditions, demographic forces, and laws and regulations all affect family structures. Social workers will not be able to avoid dealing with family issues, even if they do not practice directly with families. Individuals carry their family around inside themselves; for many people, families are at the core of their identity and can arouse a mixture of intense feelings including love, hate, guilt, joy, and sadness. Cultural differences can be critical in understanding a particular family but may not always be directly relevant; it is therefore necessary to approach each family as unique. Iversen and Armstrong (2007) explain that learning about a family’s situation is akin to engaging in an ethnographic study where the social worker helps the family narrate its story. Chung (2006) emphasizes the importance of the subjective meaning Chinese immigrant parents and children may ascribe to particular behaviors, while Ying and Han (2007), also concerned about strains within Chinese immigrant families (and more broadly Southeast Asian Americans), offer a scale to assess intergenerational conflict. In considering permanency planning for children, Waites, Macgowan, Pennell, Carlton-Laney, and Weil (2004) suggest means

of adapting family group conferencing (FGC), a strengths-based approach, for applicability across cultural groups. Owens (2003) reports on families as sources of support and stress in her examination of African-American women living with HIV-AIDS. What seems most critical is not knowledge about the many cultural differences but rather how the family system interprets its experiences and constructs its realities in a cultural context. Not distinct to human beings, family systems are evident in other animal species for reproduction and for raising the young. The system refers to the family as a group and includes a range of subsystems such as the children, parents, and extended family members. A systemic approach has provided the basis for many of the models used by social workers with attention to the family structure, hierarchy of authority, gender roles, family patterns over time, interactions among the family members, and interactions between the family and other social networks. Systems theory was first introduced by biologists in the 1950s, and Engel (1977) is credited with applying this model to medical practice. Viewed as a tool of analysis or way of organizing data, the benefits of systems theory include viewing interactions with families from a process perspective that is nonlinear and transactional, while also recognizing that the family system is greater than the sum of its individual members. In the 1990s, what had been viewed for several decades as revolutionary began to receive criticisms. A systems perspective was seen by some as reinforcing hierarchies of authority based on gender biases and as emphasizing power differentials between practitioner and family (Atwood, 2001; Rodman & Schaler, 2001; Segueno, 2007). Pare (1995) advocated a paradigm shift from systemic concepts to the family as a “storying culture,” and narrative models emerged from poststructural thought (Hoffman, 2002; White, 2000). Freeman and Couchonnal (2006) combine narrative and culturally based approaches, while Becker,

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Hague, and Liddle (2002) advocate a systemic (as well as strengths-based approach), multidimensional family prevention (MDFP) to enhance engagement by the family. Donovan (2007) advocates for a reflecting approach, which she believes synthesizes systemic and psychoanalytic concepts: “interventions of the psychoanalyst will probably veer more towards the intrapsychic/relational end of the spectrum whilst the systemic practitioner’s primary focus on balance is more likely to rest at the interpersonal/relational side of the spectrum” (p. 229). Issues of gender and sexual identity require attention in practice with families. Although often lumped together, these orientations may be related but are nevertheless distinct. Gender refers to appearing masculine or feminine while sexuality refers to same- or opposite-sex attractions. One’s sexual orientation does not necessarily determine one’s gender identity, just as taking on a female role does not necessarily translate into sexual attraction for males. Non-conformance to the societal norms raises a range of biopsychosocial challenges for that individual as well as for the family who may benefit from social work help in policy practice, community resources and family practice. Gender is often the determining factor for role expectations in many families and across cultural groups. Segueno (2007) provides a global perspective on trends in gender norms and stereotypes, while Atwood (2001) and Rodman and Schaler (2001) discuss implications of gender bias for practice with families. Yarhouse (2003) points to the second stigmatization of HIV and AIDS for families with members who are gay, lesbian, and bisexual furthering their marginalization. In describing therapeutic interventions with families, LaSala (2000) uses the “coming out crisis” for families with gay and lesbian children as a model for helping family members to talk together about feelings, to reeducate families toward a more tolerant world view, and to help the family achieve greater intimacy, while Sanders and

Kroll (2000) use the narrative approach to generate stories of resilience in practice with gay and lesbian youth and their families. Green, McAllister, and Tarte (2004) developed a strengths-based practice inventory (SBPI) to ensure that practice includes identification and use of family strengths, cultural competence, interpersonal skills and knowledge, and relationship building, and Smith and Hall (2008) describe a strengths-based family orientation to use for adolescents with substance abuse problems. Rait and Glick (2008) point to the need for renewed emphasis on family therapy training for psychiatric residents and the importance of using a biopsychosocial perspective. This might include gathering family of origin (FOO) history that covers physiologic issues (illnesses and disorders, disabilities), psychological history (cognitive and affective capacities), and social functioning (relationships, supports, educational level, occupations). The type of important information that could be found in a family history is evident in research by Laursen, Labouriau, Licht, Bertelsen, and Munk-Olsen (2005), which supports the genetic basis for psychiatric disorders: “schizoaffective disorder may be genetically linked to both [schizophrenia and bipolar disorder], with schizoaffective disorder being a subtype of each or a genetic intermediate form” (p. 847). Research by Stockdale et al. (2007) provides support for the importance of social context in their examination of linkages between community, substance abuse, and mental health disorders. Tensions for family practitioners, similar to tensions for those providing services in groups, include whether to insist on participation of all family members, whether to see individuals separate from the family as a whole, and choosing from the wide array of family therapy models including Bowen, object relations, humanistic, structural, narrative, symbolic/ experiential, and psycho-education, among many others. Good sources about social work practice with families include Goldenberg and

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Goldenberg (2008) and Nichols and Schwartz (2004). Moreover, collaboration between social work and other disciplines is even more complex in coordinating services, empowerment, and protection from harm in family work. Practice with families requires appreciation of the richness of family life, the interactions within the family and between the family and its social environment, and its history over time in order to be able to draw from multiple frameworks for practice that is creative and effective. Just as other persons, social workers have particular ideas about good versus bad families and hold stereotypes about what is normal, despite the rapidly changing social norms. It therefore is important to practice differential use of self (discussed fully in chapter 7); avoiding any engagement with family issues is not feasible, whether as a direct practitioner, community organizer or policy practice. CASE NARRATIVE: DISCUSSION BY NICOLA AND JOAN—MULTIPLE LEVELS OF PRACTICE

Here Nicola talks with Joan about the need for multiple levels of practice and strengths-based work with the Lawlers in changing family patterns over time. Nicola’s 15 years of experience in practice with children and families has made it very evident that broad and inclusive approaches are necessary. We will also hear from her in later chapters. Joan: Most of the families, not all, but most of the families we work with live in extreme poverty and, you know, I work across two housing estates and one of them historically has always been known for very poor quality housing, very high unemployment on this estate, big sort of racial mix on the estate, and so there are lots of kinds of high-stress indicators for families before they even come out of the front door. One of my families—the Lawlers—has low education standards, generation link, third-generation unemployed, using drugs, the parents have survived that, and you say “Try and get Jimmy to school” and they say “I left

school when I was 13, what’s wrong with that?” so therefore they have no higher aspirations for their own kids because that’s all they know, and that becomes really difficult to work with, and so certainly my driving force in working with families is about empowering them— helping with supports and helping them see they can help their kids do better, finish school, be successful. Nicola: The housing and the financial side are so important though; there is no empowerment without a house and food. Social work does not deal as much in class and poverty issues as we used to. We’re paying less attention to values, which is interesting because our framework certainly within children’s services is children in need and their families. So it should be a family community but also the larger community, but we can’t empower families when they are so poor and have no hope. So it’s the community as well as the family, and our training here to stress empowerment means help with the housing, food, and even safety in the community. Joan: Right, if that’s ignored—environmental issues—what’s happening in the families’ lives, the poverty, neighbors, networks of support, and so forth that side of the triangle is often completely ignored when social workers are making assessments, so you’re not getting the whole picture, you’re forgetting that they’re living in high stress, high poverty, poor nutrition, but you can’t remove that from the picture. And so how am I to help Jimmy and his siblings? It’s critical that I help them break the poverty and school truancy for this generation. Nicola: Without the supports, it’s the end of the social worker and social work. Joan: The mum was always very defensive and I was just trying to explain to her the value for her child of really working closely with the school because this was about her children, and she said to me “I can’t because every time I walk into that school they look at me like I’m a drug user.” So I worked very hard with her

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to try and get her to refrain that to think all they were worried about was Jimmy getting to school on time and how important is his education and his right, and your legal responsibility. And then I brought her to a parent group held at a school meeting for parents of children of concern for a variety of reasons, educationally, behaviorally, or child protection-wise. Once she began to regularly meet with others (I accompanied her for a few weeks until she built a connection with the others), I focused on the parenting first, not her drug use. And would you believe, once Jimmy was no longer truant, she started getting help to stop using. This discussion illustrates the necessity of incorporating the multiple levels of practice in work with families. The social work perspective of person in environment in building social supports and meeting basic concrete needs enabled Joan to help the Lawlers with housing and food needs. She was also able to help them end two destructive multigenerational patterns—school truancy and drug use. Once their son Jimmy’s school truancy ended, he began doing better work in the classroom; following this change, the mother began to focus on her drug use.

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CASE NARRATIVE: ALICE AND THE ROBINSONS—GENDER ROLES, VIOLENCE, GLOBAL CONSCIOUSNESS

Here and in chapter 7 Alice discusses gender violence in the home and global consciousness. She has been a child care worker for almost two decades, practicing in different areas of the United Kingdom. In my case load, I deal a lot with repetitive sexual abuse. In one family, the Robinsons, there was no respect for females who were viewed as objects rather than people. The mother, Indira, and three daughters—3, 5, and 7 years old—were all sexually abused. At one point, mother was thrown out of the family, at which time we were alerted by the coppers who had arrested the husband/father.

She’d been married five times, twice to sexual abusers, the other three times to either violent or criminal men with a large criminal background. Indira’s mum moved here to the United Kingdom when Indira and her siblings were small to escape from a country where abuse of women was not only common but accepted practice. We placed Indira and the children in a shelter that had counseling from a women’s rights perspective; she’s actually standing on her own two feet and doing something well. When the behavior is not criminal, we work with the whole family to re-socialize all members to a different view of gender and relationships between men and women. It’s hard to undo generations of cultural practices and the ways both the men and women think about girls and women as sexual objects. I have to work with myself as well to not judge the people as bad, but to think from a global consciousness perspective—all have inherent dignity and worth. Using reflexivity to be attentive to my own internal world, I also used critical consciousness and read the professional literature helping me to think critically and not emotionally about the Robinsons’ situation. Alice’s work with the Robinsons illustrates how the meaning ascribed to gender roles can result in severe sexual abuse. In societies that consider such behavior as criminal, protection and a range of therapeutic approaches can alter conceptions about gender with corresponding positive interactions between men and women. Whereas in societies that accept violence against women, changes may focus more on advocacy practice and policy changes to effect behavior changes, in addition to direct work with the family to protect members from harm.

Biopsychosocial Practice Accurate assessments and effective interventions in contemporary practice now require social workers to incorporate physiologic factors (chemistry, neurology, genetics, physiology) with psychological factors (cognitive, affective, and emotional functioning), along with the traditional social variables

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(community resources, social supports, income, education, and housing). This paradigm fits well with global consciousness in its inclusion of the biosphere, society, culture, organisms, and cells (Engel, 2003) and points to the need for social workers to consider opportunities and choices that are feasible from a biopsychosocial perspective.

Some clients have specific predispositions (such as a lot of cancer or addictions in the family history), while the serious challenges for others stem from family relationships or high crime in their communities. The debate of whether nature or nurture is more important has long been one of social work’s tensions, relating as it does to social work’s dual roots in social reform and individual change. Expectations for the systems and ecological perspectives adapted in the middle of the 20th century not only to shift away from a disease-based and deterministic approach but also to have a more integrative and holistic view inclusive of multiple and changing perspectives were not realized. The Civil Rights movement and War on Poverty energized social and community activism for some social workers, while practice with individuals remained based on the medical model with these social workers becoming more narrowly focused in their movement toward greater status via licensure. Frankel, Quill, and McDaniel (2003) bemoan the continuing challenges about nature versus nurture and believe the biopsychosocial model is a paradigm shift, “that disease and illness do not manifest themselves only in terms of pathophysiology” but “may simultaneously affect many different levels of functioning, from cellular to organ system to organism to person to family to society” (p. 23). They further state that this perspective “does require that one consider a human being to be both a biological organism and a person who lives in the context of family and community . . . it provides an integrative focus and relational context for understanding a range of problems” (p. 25). Epstein et al. (2003) points out that for physicians, this model has moved beyond seeking psychological causes of physical

illnesses, but “allows for multifactorial causation, and . . . explores the biological, psychological and social ramifications of all illnesses” (p. 34). For example, in treating someone with diabetes, both the physician and the social worker must recognize that though the disease is not caused by psychological issues, these may affect an individual’s capacity to control glucose levels and social functioning, while the social supports will affect the level of resources available. Just as some medical practitioners may neglect the importance of the social in their diagnoses and treatment of patients, some in social work may still ignore consideration of the biological, as suggested by Kramer’s (1993) claim, “In time, I suspect we will come to discover that modern psychopharmacology has become, like Freud in his day, a whole climate of opinion under which we conduct our different lives” (p. 300). Despite the popularity of the drug Prozac (and other drugs that gained public favor), professional practitioners and laypersons still view mental disorders as different from the physical. Research by Deacon and Baird (2009) indicates that a chemical imbalance explanation seemed to reduce clients’ sense of blame for their problems (i.e., not their fault), but these clients felt greater pessimism about recovery (deterministic) and the use of nonbiological treatments. In other words, a pill and confirmed presence of a physical problem was preferred, diminishing the potential gains from social and psychological interventions. Compelling research about the brain that began in the 1990s has continued, offering clarity about the biological component of psychological issues: “brain cells respond to the release of dopamine through one or more of five distinct dopamine receptors. . . . scientists have detected a modest connection between a relatively elongated version of dopamine receptor No. 4 and a tendency toward impulsivity and risk-taking behavior” (Angier, 2009, p. D1). Numerous other studies verify the physiologic basis of emotions and psychological problems, providing support for pharmacological treatment as a necessary component of mental

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health care. Vance’s (2010) research with magnetic resonance imaging, a specialized scan that measures changes in blood flow, shows link-specific brain activation in people experiencing a placebo effect. Furthermore, research from the emerging field of behavioral epigenetics shows definitive interactions between genetic predisposition and the environment (Kiing, Low, Chan, & Niehart, 2012). Gorman (2014) and Changeux (2013) discuss research to understand the brain’s inner language including attention to the types and roles of neurons and their interactions with each other (2014). It is attention to these many domains that explains development and behaviors and improves the potential for client change. Although some may still challenge this thrust in biology, chemistry, and genetics, social workers must acknowledge the physiologic basis of emotions and psychological problems, the relationship of neurologic phenomena to physiologic mechanisms in the brain, and the role that genes play in behavioral conditions (Hall, Scheyett, & Strom-Gottfried, 2008).

Carey (2011a) reports on an intriguing study that has recorded the actual brain traces of contextual memory: by illustrating the impact on memory of the sequencing of events, such linkages point to memory as interactive and fluid. Not only is there continuing brain neurologic plasticity, but also learning and the environment can contribute to the brain’s capacity to form new connections (Garland & Howard, 2009). Furthermore, drug effects can cause physiologic reactions that create psychological stress. For example, some antipsychotic medications can add to or worsen weight gain through an insulin reaction (Fenton & Chavez, 2006). Alladin’s (2009) model for community health care considers biological, psychological, and social functioning. Recent studies indicate the presence of viruses specific to and unique for each and every individual. Each person has a viral identity—a pattern of viral DNA that is highly stable and highly distinct, even among closely related humans (Reyes et al., 2010).

CASE NARRATIVE: GREG AND BART—AUTISM, SCHOOL PROBLEMS, FAMILY WORK

Greg, a social worker in a suburban school, discusses his work with Bart from a biopsychosocial perspective. We follow his work in chapter 4. I have been practicing as a school social worker for more than 10 years and have been fascinated with changes in the field. It’s almost impossible now to not deal with issues of medications in addition to those traditional ones of school behavior as well as the child’s family and social world. Bart is 6 years old, his parents are professionals (mother is a development officer for a large nonprofit setting, father is a treasurer of a corporation), and there are two siblings, a 4-year-old sister and 8-year-old brother. This is Bart’s first year in the school’s first grade class for gifted students with special learning needs. Initially diagnosed at the age of 4, the school’s recent evaluation confirmed him at the high end of the autism spectrum. He shows rigidity, relies on labeling over social interaction, and has tantrums especially with particular classmates and teachers (these can become violent with screaming, crying, and fighting). Highly verbal and intelligent, Bart can talk about feeling out of control. His trouble is in managing social interactions; he cannot identify any one he would consider a real friend and complains of bullying by the other kids. While I stay informed about the medications prescribed for my clients and know that the information I provide for the prescribing physician is important, I am also aware of the many debates regarding medicating children and youth and discrepancies between the types of medications used based on family income. Wilson (2009) reports that poor children whose families receive Medicaid are 4 times as likely to receive powerful antipsychotic drugs than those from families with private insurance. Without definitive data about the effects of this disparity, I haven’t drawn

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conclusions other than to be attentive and ask questions. The potential of harm to early brain development has to get considered alongside the social and psychological harm without the chemical help for these youngsters in managing their social and psychological worlds. There have been other debates relevant to my work with these kids. A major one has been the recent change in the DSM to drop Asperger’s syndrome as a separate disorder and to incorporate it as on the autism spectrum (Baron-Cohen, 2009; Carey, 2012). I meet individually with Bart a few times a week: We talk about how he is getting along with his teachers and other students and also about his home life. These therapeutic interventions have become meaningful for both of us. I also provide family therapy in their home, which includes everyone including the siblings (Koenig & Levine, 2010). These discussions address some of the psychological and social issues for Bart both within the family context and in the wider social world of extended family, friends, neighbors, community. Team meetings are also held at the school where we all have a chance to discuss Bart’s progress and continuing problems to ensure we are providing a safe school environment that fosters his success. The biopsychosocial perspective guides everything I do as a practitioner. It’s not possible to provide effective services to kids in schools without paying attention to conditions that may need medications, their social world, and how well the school is educating and serving their needs. I stay informed about research; a recent article on prenatal care definitively pointed to the importance of both person and environment. In a study of twins, 77% of the male identical twins and 50% of the female identical twins exhibited autism spectrum disorders in both children; rates were lower for fraternal twins, 31% of males and 36% of females. Nonetheless, the article reports that mathematical modeling indicates that genetic factors could only account for just 38% of the cases, with shared environmental factors significant for 58% of the cases (Tarkan, 2011). It’s wild to acknowledge prenatal care as part of the child’s

environment, albeit before birth. I was especially excited to read Grandin and Panek’s (2013) book; it was hard to believe that from Temple Grandin’s diagnosis of autism at an early age (suggesting institutionalization) she now teaches and writes from a personal and scholarly perspective about living with and treating autism. Note Bart’s emphasis on drawing from the professional literature to stay current with debates about diagnoses and medications. Recognizing the potential harm to children and families from a narrow approach, he never strays from his strong biopsychosocial perspective.

The Direct and Clinical Practice of Social Work Direct practice with individuals has remained the most dominant form of social work practice. Just as the mandate for social workers who focus on policy, management, and community practice is to remain attentive to the needs of individuals, it is also incumbent on direct and clinical social workers to embrace the multiple levels of practice with special focus on the social. The easy abbreviations of macro for the former and micro for the latter have become acceptable jargon for many social workers. A variety of terms have been used to describe social work focused on individuals: social casework was the name used by the early founders of the profession. At the beginning of the 21st century in the United States, the terms generalist and direct practice along with clinical for more advanced work are frequently used to identify the arm of social work that emphasizes individual change—helping individuals to improve their social functioning. Concerned with how individuals lived as social beings in their society, Mary Richmond (1922) initially defined social casework as “those processes which develop personality through adjustments consciously effected, individual by individual between men and their social environment” (pp. 98–99). In later years,

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she focused on the broader picture; “the art of doing different things for and with different people by cooperating with them to achieve at one and the same time their own and society’s betterment” (Richmond, 1930, p. 374). Another important social work theorist, Gordon Hamilton, also pressed for attention to individuals and society: Society is inseparable from the individuals who compose it . . . one must infer that self-awareness, or finding oneself, and being able to relate oneself to society are two ends of the same process.  .  .  . The casework idea . . . may be utilized whenever people have impaired capacity to organize the ordinary affairs of life or lack satisfaction in their ordinary social relationships. The idea that we are concerned with social reality and social adjustment is fundamental. (Hamilton, 1940, pp. 28–29)

These holistic conceptions by Hamilton influenced Hollis’s later psychosocial approach, which “is characterized by its direct concern for the ‘well-being’ of the individual. . . . This emphasis upon the innate worth of the individual is an extremely important, fundamental characteristic of casework. It is the ingredient that makes it possible to establish the relationship of trust that is so essential for effective treatment” (Hollis & Woods, 1981, p. 25). She further asserted that the caseworker’s function should be to place “direct action upon the mind” to help the individual to change (p. 101). Spanning the early 1900s work of Richmond to the 1980s version of Hollis and Woods, the themes were importance of relationship in practice with individuals within the context of a wider world. Good historical sources include Roberts and Nee (1970) and Siporin (1975). While individual change was the acknowledged specialty of social casework, the importance of the “social world” continued to cycle in and out of attention. During the 1940s and 1950s, Freudian theory became popular; social workers shifted away from a “brain disease” view of the mental illnesses while retaining a

“medical model” focus on the individual and the intrapsychic. The licensure movement gained momentum in the 1980s: Social work practice with individuals, families, and small groups came to be called clinical social work, which relied on insight and increased selfawareness to create individual change. Responding to tensions about the parameters of social work with individuals, the NASW, the professional organization for social workers that sets the standards for practice, states in its Introduction to the Standards: Clinical social work is broadly based and addresses the needs of individuals, families, couples, and groups affected by life changes and challenges, including mental disorders and other behavioral disturbances. Clinical social workers seek to provide essential services in the environments, communities, and social systems that affect the lives of the people they serve. (Barker, 2003; NASW, 2005)

The association further explains that clinical social workers use a psychodynamic perspective: This word pertains to the cognitive, emotional, and volitional mental processes that consciously and unconsciously motivate an individual’s behavior. These processes are the product of the interplay among a person’s genetic and biological heritage, the sociocultural milieu, past and current realities, perceptual abilities and distortions, and his or her unique experiences and memories. (Barker, 2003; NASW, 2005)

Barker (2003) considers clinical social work as synonymous with psychiatric social work and social casework, defining it as “the professional application of social work theory and methods to the treatment and prevention of psychosocial dysfunction, disability, or impairment, including emotional and mental disorders” (p. 76). Clinical social work services consist of assessment; diagnosis; treatment, including

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psychotherapy and counseling; client-centered advocacy; consultation; and evaluation. Interventions are directed to interpersonal interactions, intrapsychic dynamics, and life-support and management issues. While this book focuses on the specifics of practice with individuals, it directly reflects the two paradigms of individuals within their environment, and biopsychosocial for assessments and interventions. Drawing explanations and illustrations from Barker (2003), Bisman (1994), Congress (2008a), Hendricks (2005), and Rosenblatt and Waldfogel (1983), direct and clinical social work with individuals is a biopsychosocial process of social workers creating change with individual people to improve human well-being, enhance individual empowerment, and promote social justice. Guided by professional ethics and values, with the use of the helping relationship, based on the assessment’s case theory, and differential use of self, social workers engage a variety of interactions for shared constructions to implement strategic interventions. The focus for change is always the person and the environment, to help individuals live better in their society. Conducted within the context of the agency, practice addresses issues of service provision and the larger community in which the individual interacts with others.

CASE STUDY: KAREN—DOMESTIC VIOLENCE, CHILD PROTECTION, MENTAL HEALTH, GLOBAL CONSCIOUSNESS

Our next social worker is Karen, who is 40 years old, white, with two biracial children, ages 10 and 6, and married to a computer programmer, born in South Africa, who earns about $85,000 a year. She and her three siblings were raised solely by their mother after the abusive father abandoned the family. Karen was very sensitive to the need for supportive services. At first her mother got money from various men. It took Karen a while to realize there was something “bad” about what was happening with her mother

(the mother’s sister kept telling her mother that she had to get a regular job or the children would have to move in with her). The mother then got work cleaning houses followed by a steady job in facilities for the local school system. (Case material here is a composite from a case discussed in Bisman, 1994. Karen’s practice is also discussed in chapter 7.) Karen has been employed by this family service agency for more than 10 years; it serves a lower middle income population and is located in a large urban area on the West Coast of the United States. Karen discusses the case: Kate, the client, is 19, white, with two sons aged 7 months and 2 years. Three years ago at the age of 16, she moved out of her parents’ home after a big fight with her mother and lived with other homeless youth in parks and under bridges. Alex, 21 at the time, befriended her, ultimately becoming her pimp and using her to raise monies for food and cigarettes. Once she became pregnant he took Kate and moved back into his parents’ house. Kate has since been receiving welfare payments of about $400 per month along with food stamps and Medicaid benefits. Children and Youth Services had recently completed an investigation of Kate responding to a report that she was abusing her children. Though no evidence of abuse or neglect was found, Kate agreed to their recommendation that she receive therapeutic services. Since her first pregnancy she has had feelings of loneliness and sadness. She now cries frequently (sometimes resulting in beatings by Alex, the boyfriend), has little energy to even spend time with her children, and having never pursued her high school equivalency (dropped out in her junior year) feels at a loss about what to do with her life. In recent conversations with her own parents, they agreed to have the two children move in with them but told Kate that she would have to move herself into a homeless shelter unless she abided by their rules. Much time was then spent with Kate and her mother on creating a home environment that would be comfortable for everyone—including a clear schedule of Kate’s duties and what they could expect from each other.

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After all this time, I am familiar with the neighboring counties and have knowledge of services available in the community and the policies that mandate the services. I am fully aware of the many issues relevant for Kate and am considering several goals for treatment. I knew that merely relying on talk therapy focusing on Kate gaining insight into her selfdestructive behavior would be too limiting in my practice with her. Not only did I have to help her explore ways to change specific living circumstances, but also I had to focus on her emotional state, safety, housing, finances, schooling, social supports, and parenting skills. Her symptoms could indicate depression, so I referred her to the agency’s psychiatrist for potential pharmacological treatment. I also had to immediately address issues of safety—for her and the children. We directly discussed the violence in her home and reviewed ways to increase safety including phone numbers for hotlines, emergency shelters, and the police. I advised her about the state policies regarding restraining orders and about child welfare legislation concerning parental rights and duty to protect children from harm. Having practiced with many clients involved in abusive relationships, one of my assumptions was that Kate grew up in an abusive home (so I knew I had to be aware of safety issues for the children but not move from assumption to reality without evidence). I was also aware of the increasing number of adolescents fleeing these problematic home environments into homelessness and prostitution. I had recently read a most relevant piece in the New York Times indicating one estimate “that at least 1.6 million juveniles run away or are thrown out of their homes annually” often turning to sex work (Urbina, 2009). So it was important that I review the past with Kate and her parents, not so much for insight, but to plan together so that the current and future living environment does not repeat the past. Family therapy was initiated for them to explore past issues of Kate’s leaving the home and to help them implement a plan to address the parents’ current

concerns about Kate cleaning up after herself, looking after the children, and contributing to household chores. In addition to the family work, I referred her to a parenting support group I ran with one of my colleagues at the agency, provided information and reading material on child development, and included discussions about a possible career path in our weekly meetings. In this group we also discussed ways for parents to handle their feelings and thoughts and to prevent their violence toward the children. On one occasion I provided transportation for Kate to acquire information about affordable housing so that she could begin thinking about planning for a home with her children. We drove through different neighborhoods considering safety and the availability of resources such as shopping, medical care, and public transportation. On another I played the role of advocate in calling the police when Alex and his family were in the parking lot of the agency at the time of Kate’s appointment. It also became clear to me that there was a shortage of affordable housing and limited hours for the bus line serving that neighborhood. I raised these issues at an agency staff meeting and the agency director decided to attend one of the county board meetings along with me and several other staff. We argued that the county provide more monies for housing and transportation; while funds were not readily available for housing, contacts were initiated with the bus company to explore the possibility of expansion in services. Note that instead of a “narrow” clinical role that focused solely on psychological issues and increased understanding, Karen’s practice reflects the biological (psychiatric referral for medications), the psychological (discussions of feelings, thoughts, and their linkage to behavior), and the social (building of social supports, issues of policy and community). Karen functioned broadly as an advocate in helping Kate connect with resources in the community and engaged in psycho-education as she broadened Kate’s understanding of her children’s needs. She met with

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Kate individually and in a group setting and also with Kate and her family of origin. Karen’s attempts to understand Kate were based on various sources of evidence to explain this client’s situation. Going beyond increased awareness and insight, Karen attended broadly to Kate’s environment. Considering the past as part of the context to explain Kate’s present circumstances was important, but as one factor among many needed to create change. Karen was diligent about reading from a range of literature sources for data about the problem of runaway youths and the potential for prostitution. She was troubled by reports indicating an increase of runaway youths from 550,000 in 2002 to 761,000 in 2008, many of who reported that they left their families due to conflicts or parents’ substance abuse (Urbina, 2009). The global perspectives on this were also alarming as a public health and human rights crisis and were highly relevant to some of her other families. She learned from Ryan and Kelley (2012) that many of these runaway kids go unnoticed. Homelessness and sexual abuse are major problems as well as risks of disease such HIV-AIDS, malnutrition, and substance abuse. Particularly at risk are LGBT youth, many of who report sexual abuse prior to leaving their homes and remain at continuing risk for sex trafficking. Representing 1.4% to 5.0% of the youth population in the United States, they compose 15% to 36% (depending on the research) of the homeless youth population (Rosario, Schnimshaw, & Hunter, 2012). Snell (2003) discusses the rise in homeless youth in South Africa. Figures reported by Lowrey (2014) about the huge amounts of money made in the sex business by pimps and traffickers (not the workers) shocked her. At the same time, she gained hope from Kristof ’s (2013) column on how one sex worker was able to “get away” and instead worked to be the “world’s best mom.”She worked with a biopsychosocial approach to help her families so that their children would not become part of that runaway population. Karen gave direct help in assisting with housing, finances, and information; attended to the policies that shape services; and enhanced the agency’s service delivery by engaging colleagues as advocates for improved community services—the environmental part of

the person–environment perspective of social work practice can be the critical factor in helping clients to change destructive patterns. We will also meet Karen in chapter 7, 15 years before her work with Kate when she is a second-year master’s student and assigned a group consisting of males who have battered their wives, partners, or girlfriends.

Summary Examination of professional occupations, including social work’s historical development as a profession, provided a lens through which to view social work’s organizing ideas. The evolution of emphasis on individual change by the charity societies and on social reform by the settlements to the profession’s contemporary paradigms of person in environment and biopsychosocial practice was described. These embrace multiple domains to address the problems faced by individuals in a complex and multilayered world and require social workers simultaneously to engage several levels of practice that are not mutually exclusive but continually interacting with each other. For person in environment these include policies, communities, organizations, small groups and families, and individuals. Biopsychosocial practice requires incorporation of physiologic factors (chemistry, neurology, genetics, physiology) with the psychological (cognitive, affective and emotional functioning) and gives special attention to the social (community resources, social supports, income, education, and housing). Case studies and narratives illustrated how social workers simultaneously target people and environments, address multiple levels, and incorporate the biopsychosocial. Although their primary practice was with individuals, they nevertheless had to be informed about social conditions, policies and regulations, and their agencies’ service provision and at times had to advocate for improved community resources, policies, and service delivery of their employing organization—the public aspect of the lives of individuals and families. Engel, a

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physician, was one of the early contributors to a biopsychosocial model and saw the art versus science controversy as “fruitless” because “the very essence of medical practice . . . remains ‘art’ and beyond the reach of science” (Engel, 2003, p. 3). This chapter laid the foundation of social work’s core concepts for further consideration of the art, science, and morality balance in the practice of social work. Exercise Consider the following questions as you read the case below. 1. Identify how the different levels of practice are relevant if you were Thomas’s social worker—policy, community, the organization, group, family, with at least one point for each level.

2. Explain the biological, psychological, and social components you would explore as Thomas’s social worker. Identify at least one of each.

EXERCISE CASE STUDY

Thomas is in his early fifties. He was married, but there’s no ongoing contact and no children, his parents now live in Australia, and he is no longer close with them. A shelter was his home for a time, but with his drinking and fighting he’s now living on the streets taking drugs when he can get them. No one is sure what he does for food. His clothes never fit right, he’s always anxious, asking the same questions over and over, and he spends a lot of time crouched on the floor talking to himself. He’s isolated and seems sad and scared.

3 Ethical Practice Toward Social Justice and Human Well-Being Local and Global Servants, labourers, and workmen of different kinds, make up the far greater part of every great political society. . . . No society can surely be flourishing and happy, of which the far greater part of the members are poor and miserable. —Adam Smith The death of dogma is the birth of morality. —Immanuel Kant I find myself always struggling to keep a good balance. On the one hand, clients have rights to privacy and confidentiality within the professional relationship, and without that feeling of trust, it’s going to be hard for them to open up. Then on the other hand, clients have the right to be protected—of me making sure that this vulnerable child is safe outweighs the right to the family to not have their privacy invaded . . . there’s also the legal matter—if someone has broken the law and offended against a child, that needs to be brought to justice. —A social worker I used to be a social worker in South Africa and now practice in Los Angeles where the mixture of people from so many nations and backgrounds is amazing. It has become clear to me that I have to think globally and from a human rights perspective in any locale—people are on the move. Social work gives me the knowledge to fight inequality, oppression, and poverty. —A social worker

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hy should society support social work’s efforts? How do social workers make ethical decisions when one ethical principle seems to contradict another? Which takes priority—cultural norms or human rights? Is the profession’s moral base still relevant for a rapidly globalizing world? This chapter considers these questions in its examination of how the profession’s vision for a better world imbues it with meaning, defines the role of the social worker, and offers a purpose for social work’s continued existence. Emphasis is on the moral ends pursued by social work and other professions to seek a “common good,” as distinct from a disciplinary emphasis on developing knowledge to explain particular phenomena. While chapter 2 focused on the ways social workers frame and apply knowledge and skills that reflect persons and environments and the biological, psychological, and social—the organizing ideas of the profession—this chapter emphasizes the application of these concepts to advance and improve the lives of people and their communities with special focus on those who have been marginalized and who have serious needs. Just as in the previous chapter, this chapter also draws from historical traditions (sociological and philosophical) to provide a context for the long-standing significance of social work’s s moral perspective and through case material illustrates practice guided by values and ethics. Social workers may not always share methods or ideologies with other professionals, but

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similar to other professionals, social workers must adhere to their profession’s mission and use a shared code of ethics and set of values. Despite the importance of a common purpose to promote social justice, agreement around the meaning of such a complex and abstract concept associated with Western philosophers across many centuries will require continuing discourse. Different interpretations of what social justice means may evolve. Furthermore, social work faces challenges in this 21st century to address ongoing troubles shared by nations such as disparity, poverty, and oppression while also attending to new dilemmas emerging from large-scale displacements, migrations of people, and the devolution of nation-states. Contexts of geography as well as of culture are therefore necessary components of practice in a global society. Global consciousness examined in this chapter and introduced in the first chapter as a new construct for social work promotes ethical practice on a global scale both within and across national borders. Case studies will illustrate how ethical decision making connects knowledge to practice, and case analyses will consider ethical dilemmas, approaches to ethical decision making, and highlight advocacy and empowerment for practice globally and locally. This chapter also explores how the values of social justice and human dignity emerge from and further expand social work’s mission to enhance human well-being and alleviate oppression and how to translate these abstract concepts into practice guided by a range of ethical codes. One of the primary goals of this book is to socialize readers into the profession’s values as shaped by its mission; it therefore covers value-guided practice drawing from several ethical codes including the International Federation of Social Workers (IFSW & IASSW, 2004), British Association of Social Workers (2002), with special focus on the National Association of Social Workers (NASW) for practice in the United States. The Canadian Association of Social Workers (CASW, 2005) received permission to draw heavily from the NASW

code; it is also consistent with the IFSW ethical code. The code of the Australian Association of Social Workers (AASW) (1999) is lengthy with clear-cut attention to a human rights perspective. They all provide local and global perspectives for ethical practice. The fact that the IFSW (2014) reports 100 member organizations in various parts of the world does not always translate into shared agreement about the meaning of social work’s mission and values. Even more contentious are the ethical standards that, with their greater specificity, can conflict with societal norms. Such disagreements of interpretation or even lack of support can also occur within nations. For example, some regions in the United States actively support government programs to protect children while others are against government “meddling in the lives of others” and favor private religious-based programs. These differences in beliefs and norms can create differences in the priorities of practitioners (Petrie, 2009). Despite these political and cultural challenges for a shared meaning of the profession’s mission, values, and ethics within and across borders, it is important to note that social work’s long-standing base in morality came before its code of ethics. Moreover, progression from an early focus on the morality of individuals to the contemporary social morality perspective brings together social work’s core organizing ideas into the new construct of global consciousness, which is explored and illustrated in this and later chapters. Social Work and Its Moral Commitment Using values and ethics in selecting theories to develop social constructions of how things ought to be as well as how things are, the sanction for professional occupations to practice is partly based on their calling to contribute to the public good. This is especially true of social work with its emphasis on human well-being and social welfare (Banks, 2006, 2008; Bisman, 2008a; Clifford & Burke, 2009; Dolgoff, Loewenberg, & Harrington, 2005; Hardcastle,

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et al., 2004/2011; Hugman, 2008; Reamer, 1999; also see IFSW , 2004, 2.2.3; National Association of Social Workers, 2005, 2008 [1996], p. 1; British Association of Social Workers, 2002, Statement 7). In chapter 2, we introduced the Society for Organising Charitable Relief and Repressing Mendicity, abbreviated to the Charity Organization Societies (COS), whose members wished to raise the morals of individuals and society: “such an organization . . . could help us to realize in society the religion of charity without the sectarianism of religion” (Loch, 1904, pp. 67–68). It took another decade for the Settlement Movement to shift the emphasis from the morality of individuals to the social morality. Recognizing the inadequacy of ideas and beliefs and that “action is indeed the sole medium of expression for ethics” (Addams, 1902, p. 273), Addams broadened the reach of the settlements from philanthropy to political action by improving services and resources, including education, for newly arriving immigrants. The current values of the profession including individual worth and dignity and social justice directly reflect the ideas and practices of both the “friendly visitors” and settlement workers. To meet the U.S. Constitution’s mandate for separation of church and state, the early American social workers had to find a moral argument, other than religious, on which to base their interventions. Addams (1902) offered that “ ‘ethics’ is but another word for ‘righteousness,’ . . . without which life becomes meaningless” (p. 1) and that the social morality provided a foundation for democracy, “to follow the path of social morality results . . . in the temper of the democratic spirit . . . the guarantee of Democracy” (p. 7). Not all believe this base in morality is a positive. Criticisms of the COS and the settlements include their religious evangelism and that they were motivated by the need for social control to prevent social unrest and by pressure to reduce the health and financial costs of poverty. These criticisms remain valid

today with concern for cost containment and a focus by some social workers on the morality of individuals rather than on the social morality. It is not the profession’s function to challenge private morality (or for that matter, the private behavior of people in public roles); social work’s mission is to act on the morality of social life— to embrace the dual areas of individual and social well-being, which together comprise human well-being and the person and environment perspective leading to the promotion of social justice. “Social morality refers to matters of the collective and to the profession’s duty to improve the conduct of social life in its moral aspect, to act on the behaviors that create the public life and impact on the public sphere” (Bisman, 2004, p. 117). The concepts at the core of the profession— social justice, human well-being, social welfare, and social morality—are ideals and therefore aspirational, lacking in clearly defined outcomes and measurements. Nevertheless, they play a critical role in both inspiring practice and knowledge development and guiding its practitioners to create change in existing phenomena. Scholars across a range of disciplines add meaningful perspectives to increase understanding of these terms; their positions are also identified to provide a disciplinary context for their comments. Bauman (emeritus professor at the University of Leeds in the United Kingdom and noted sociologist from Warsaw) reminds us just how difficult this work is in that one “cannot beat ambivalence; s/he may only learn to live with it. The context of life . . . is messy” (Bauman, 1994, p. 182). There are inherent paradoxes in social work, yet its business is the “redemption of moral capacity and . . . remoralization of human space” (p. 240). Social work’s mission to enhance human well-being provides its moral authority; Downie (professor of moral philosophy at the University of Glasgow, the same position held by Adam Smith) and Telfer explain “it is society’s welfare, then, not the client’s moral welfare, which is his ultimate concern” (Downie & Telfer, 1980, p. 33). Also

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addressing the direct service aspect of social work practice, Downie (1971) acknowledges “the fulfillment of these minimum social rights can be regarded as a necessary condition for the exercise of any rights whatsoever; there can be no rights to life or liberty without bread” (p. 81); he later adds, “We judge a society not only in terms of the amount of benefit but also in terms of the way the benefit is distributed” (Downie & Telfer, 1980, p. 40). Tronto’s work reflects Bauman’s vision for a “caring” paradigm as part of the social welfare, one that is both moral and political where human care and interdependence are categories of social life that structure our realities across gender, race, and class (Tronto, 2010). Appiah (philosophy professor) talks of a sociality of mutual dependence that takes into account the ethics of identity as well as personal autonomy, both requiring societal support (Appiah, 2005). Capabilities and freedoms of opportunity are Sen’s (professor of philosophy and economics) views from a development ethics perspective to protect liberty and reduce poverty (Sen, 2009). A good society is one that is a caring place not only for our local communities but also beyond our national borders and wherein there is access to basic resources such as food, housing, education, health care, all basic to a free society. Consideration of the norms and practices that sustain inequalities for the powerless and disadvantaged is the means Koggel (philosophy professor) advocates for alleviating oppression and enhancing equality; she argues this should cover a global society with its inequalities within and across borders. Such knowledge, asserts Koggel, is needed to identify “both the people disadvantaged by their membership in particular groups and the inequalities experienced by them” (Koggel, 2002, p. 255). A prerequisite to a flourishing of a people, or attention to the social welfare, is moral agency. Attention by social workers to self-determination empowers others to pursue their welfare as well as the social welfare.

Social Work Mission and Values As we see in the earlier discussions, while it is difficult to translate the very abstract concepts of social work’s mission and values into practice behaviors, without clarity the profession cannot achieve its goals (DiFranks, 2008; Johns & Crockwell, 2009; Ogden, 2008). For contemporary practice, it is necessary to frame a shared understanding of the profession’s purpose and practice on a global scale taking into account the complex interplay of values and cultural practices. Mission statements articulate a profession’s purpose along with its values, covering both breadth and specificity and avoiding jargon. Inspirational to its members and grounded in real-life changes to achieve through its practice, mission statements should also capture those outside the profession who must understand its mission; as public support is crucial to a profession’s viability. Although the mission of social work may vary slightly among different nations, the concepts of social justice and human well-being regularly appear. Social work’s emphasis is to change the behavior of individuals and society; this is the nexus of the profession’s domain. Consequently, social work’s mission must embrace both individual and social well-being for practice with the person in environment perspective in order to enhance human well-being and lead to the promotion of social justice.

Social justice means fairness and access to opportunities for social mobility and improved potential for individuals and society—a better life for all people. It requires tolerance for diversity and a broad and inclusive focus on the morality of social structures and policies as they influence both the social life and the private lives of individuals. This is what distinguishes social work and what informs and guides its knowledge and skills. A range of ethical codes provide examination of social work’s historical base in morality within the context of its status as a professional occupation. Focus is on the direct linkages

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between its mission and the values of service, human dignity and relationships, integrity and competence. The preamble of the NASW code states: The primary mission of the social work profession is to enhance human well-being and help meet the basic human needs of all people, with particular attention to the needs and empowerment of people who are vulnerable, oppressed, and living in poverty. A historic and defining feature of social work is the profession’s focus on individual well-being in a social context and the well-being of society. Fundamental to social work is attention to the environmental forces that create, contribute to, and address problems in living. Social workers promote social justice and social change with and on behalf of clients. (NASW, 2008 [1996], p. 1)

For its definition of social work, the IFSW draws on a range of international documents including the United Nations such as the Universal Declaration of Human Rights (1948) and the Convention on Rights of the Child (2012), stating in its code, “Principles of human rights and social justice are fundamental to social work. International human rights declarations and conventions form common standards of achievement, and recognise rights that are accepted by the global community” (IFSW & IASSW, 2004, pp. 1–2). Values provide the underlying framework for a profession’s mission, which in turn distinguishes professional occupations by grounding them in a purpose and service to a larger good: ethical codes guide the profession’s practice.

Values refer “to attitudes for desirable goals and end states that are thought ideally to fulfill basic human needs and to benefit people individually and collectively” (Siporin, 1975, p. 65). Reamer, who has written extensively about ethics and values, explains that they provide structure for organizing behaviors especially in social work as one of the most

normative of the helping professions in that its “historical roots are firmly grounded in concepts such as justice and fairness . . . mission has been anchored primarily, although not exclusively, by conceptions of what is just and unjust and by a collective belief about what individuals in a society have a right to and owe to one another” (Reamer, 1999, p. 5). This normative nature of social work practice means that it cannot be value free. Upholding specific belief systems and value orientations, social workers are employed by agencies reflecting certain values and beliefs, and they intervene with clients who have their own beliefs, values, and traditions. The following presentation of values draws heavily from the standards and code of the National Association of Social Workers (2008 [1996]); the International Federation of Social Workers (IFSW & IASSW, 2004), and the British Association of Social Workers (2002). A global perspective is becoming increasingly necessary for the many social workers who practice beyond particular national borders. All social workers need direct knowledge of the ethical code in use within the national borders in which they practice. After presentation of basic information on values and ethics, case material in the section on ethical reasoning illustrates how values and ethics inform and guide practice. Service Service by professional occupations seeks a larger good through caring and changing.

Such altruism supersedes a professional’s own self-interest. Accepting a “calling” has long been associated with professionals as a moral commitment to serve the community by actions toward a greater good in public phenomena such as education, health, or social life. Service to the society, shaped by the profession’s values and ethics, is unique to professional occupations and what defines and shapes its knowledge and skills. A profession is more than an occupation using sophisticated techniques. Professions, therefore, exist with public

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protection and sanction because of their benefit to communities, the public, clients, and the common good. Tawney (professor of economic history at the London School of Economics in the early 1900s and who also worked at Toynbee Hall—one of the early social work settlements) states that the meaning of the profession’s actions, for social workers and the public, is “that they make health, or safety . . . or good law” (Tawney, 1948, pp. 94–95). Research serves the public good in the provision of knowledge to enhance the particular social goods serviced by that profession. Contemporary challenges to this value include increasing commodification, outsourcing of services, and for-profit settings. Some have considered the service attribute so distinguishing of social work as to call it “humanitarianism in search of a method” (Cohen, 1958, p. 3). Flexner, in his seminal report in the early 1900s on professional occupations, included service as one of his criteria and rated social work high in seeking “the advancement of the common social interest” (1915, p. 581), later expanding “in the long run, the first, main and indispensable criterion of a profession will be the possession of professional spirit, and that test social work may, if it will, fully satisfy” (1915, p. 590). The ethical principle is stated in the NASW code (2008 [1996]): “Social workers’ primary goal is to help people in need and to address social problems.” Here, directly stated, is the person in environment perspective introduced in chapter 1. Further elaboration states: “Social workers draw on their knowledge, values, and skills to help people in need and to address social problems” (p. 5). The ethical Standard 6.01 continues: “Social workers should promote the general welfare of society, from local to global levels, and the development of people, their communities, and their environments” (p. 26). The BASW code elaborates that social workers “have a responsibility to help individuals, families, groups, and communities through the provision and operation

of appropriate services and by contributing to social planning” (British Association of Social Workers, 2002, Section 2). Social Justice The thrust of the profession’s mission is social justice. We draw from several codes to help define this highly abstract concept, which encompasses the social morality discussed earlier. Despite its core significance for social work, there are valid criticisms about the continuing lack of clarity about the meaning of social justice (Banerjee, 2011; Solas, 2008). As Reisch (2002) exclaims, it is not possible to teach and learn about social justice if we do not understand what it means In this book, social justice refers to equality of access, increase of fairness, decrease of disparity, and promotion of equality of opportunity (housing, education, health care, safety, employment, among others). Its vision covers improved potential for individuals and society, a widening of the range of possibilities and feasible options for a better life with dignity. Seeking social justice involves a range of actions including alleviating poverty, advocating to reduce the unequal and unfair distribution of goods and services, and empowering those who are oppressed and vulnerable.

One of the foremost Western philosophers, Aristotle (third century b.c.), argues that justice requires nonarbitrary treatment of people with the task of government to allow citizens the possibility of living a good life (Salkever, 2009). More recently, Rawls (1971, 2001), drawing from the ideas of Locke (1690 [1978]), Mill (1863 [1957]), and Rousseau (1762 [1782]) about the social contract, established a system for equalizing distribution of the primary social goods of liberty, freedom, opportunity, income, and wealth to ensure all people do their fair share and do no harm. Fairness received greater emphasis in his revised approach (Rawls, 2001). Reamer (2012) also discusses fairness seeing it as “social work’s enduring and admirable preoccupation” (p. 109). Others have worked on

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providing specificity for this broad and complex concept (Reamer, 2012; Reisch, 2002, 2013; Wakefield, 2005b). Martin Luther King Jr. captures the spirit of social justice in his 1963 “I Have a Dream” speech (various parts captured in the following): A dream of equality of opportunity, of privilege and property widely distributed; a dream of a land where men will not take necessities from the many to give luxuries to the few; a dream of a land where men will not argue that the color of a man’s skin determines the content of his character; a dream of a nation where all our gifts and resources are held not for ourselves alone, but as instruments of service for the rest of humanity.

Striking in King’s memorable speech is that seeking social justice for all people involves increasing sensitivity to and knowledge about poverty, oppression, and discrimination and tolerance for diversity (inclusive of race, ethnicity, religion, culture, gender, sexuality, among other differences). Promotion of inclusivity while minimizing exclusivity has become ever more critical for social work practice in the 21st century and is more fully discussed later in this chapter in the section on global consciousness. The ethical principle “Social workers challenge social injustice” states that “Social workers pursue social change with and on behalf of vulnerable and oppressed individuals and groups of people. . . . Change efforts are focused primarily on issues of poverty, unemployment, discrimination, and other forms of injustice” (NASW, 2008 [1996], p. 5). This is later developed in Standard 6.01: “Social workers should advocate for living conditions conducive to the fulfillment of basic human needs and should promote social, economic, political, and cultural values and institutions that are compatible with the realization of social justice.” Standard 6.04, Social and Political Action, further develops these ideas: “(a) Social workers should engage in social and political action

that seeks to ensure that all people have equal access to the resources, employment, services, and opportunities they require to meet their basic human needs and to develop fully. Social workers should be aware of the impact of the political arena on practice and should advocate for changes in policy and legislation to improve social conditions in order to meet basic human needs and promote social justice” (NASW, pp. 26–27). The British code includes, “Social workers have a duty to . . . bring to the attention of those in power and the general public, and where appropriate challenge ways in which the policies or activities of government, organizations, or society create or contribute to structural disadvantage, hardship, and suffering or militate against their relief ” (BASW, 2002, Section 3.2.2.a.). The IFSW code also identifies that social workers “have a responsibility to promote social justice, in relation to society generally, and in relation to the people with whom they work” (IFSW & IASSW, 2004, p. 2) to “ensure that resources at their disposal are distributed fairly, according to need . . . to bring to the attention of their employers, policy makers, politicians, and the general public situations where resources are inadequate or where distribution of resources, policies, and practices are oppressive, unfair, or harmful” (p. 3) and “have an obligation to challenge social conditions that contribute to social exclusion, stigmatisation or subjugation, and to work towards an inclusive society” (IFSW & IASSW, 2004, p. 3). Dignity and Worth of the Person Social work practice often involves change of problematic activities by individuals. The thrust in this value is that regardless of particular behaviors, all people have inherent dignity and worth; all people, regardless of their actions, deserve caring and respect as well as opportunities to enhance their well-being.

Arguing for the singular importance of human dignity, Kant (1785) believed that it and morality were not even values (which were

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subject to judgments of right or wrong), but were instead “ends in themselves.” Therefore, morality and humanity alone each have inherent dignity and are associated with human will and agency. (Note: This will be further described later in the discussion of autonomy and selfdetermination.) Centuries later, Gewirth (1978, 1996) added to Kant’s ideas that in addition to not causing harm, human dignity requires aiding others to have an improved state of wellbeing. From Mill’s (1863 [1957]) perspective, “all beings possess in one form or another” “a sense of dignity,” while for Appiah (2006), respect for all people must guide social services. In his discussion about what constitutes moral behavior, he emphasizes “how we ought to treat other people if we are to flourish ourselves; and how the ways in which we should treat other people depend on what it takes for them to flourish” (p. 9). Kateb (2011) considers human dignity as an “existential” valuing of individuals’ identity as human beings. Recognizing the uniqueness of humans, he also acknowledges that individuals have responsibility to recognize dignity of the human species and of nature at large. The ethical principle in National Association of Social Workers (2008 [1996]), “Social workers respect the inherent dignity and worth of the person,” is elaborated as “Social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self determination” (p. 5). Standard 1.05 further states, “(c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability” (p. 9), and Standard 4.02 adds “Social workers should not practice, condone, facilitate, or collaborate with any form of discrimination” (p. 22). The IFSW code specifically emphasizes focus on strengths in item no. 4, included in Principle

4.1, Human Rights and Human Dignity: “Social workers should focus on the strengths of all individuals, groups, and communities and thus promote their empowerment” (IFSW & IASSW, 2004, p. 2). Importance of Human Relationships It is through the vehicle of the professional helping relationship that social workers create change in a range of individual and social conditions such as mental illness, poverty, oppression, inequality, discrimination, homelessness, unsafe communities, unemployment, elder and child abuse and neglect; and also empower clients, fostering selfdetermination and agency.

Actions to develop such relationships include building a belief-bonding and a collaborative working relationship with client systems and seeking to strengthen social relationships to foster strong families, communities, and organizations. Social supports and networks are integral to relationships that allow for human well-being and the promotion of social justice. Building on the philosophical arguments for inherent human dignity and worth, there is broad recognition for the centrality of relationships. Appiah’s (2008) contemporary approach to Aristotle’s ideas about eudaimonia, defined as flourishing (having a good life), emphasize that for individuals to flourish, they must be involved with and facilitate the flourishing of others. Furthering what is now called virtue ethics, feminist philosophers also emphasize relations and caring arguing that one’s social connectedness defines one’s ability to be a moral person with agency (Bisman, 2008b). Tessman (2002) argues that “the pursuit of one’s own flourishing cannot qualify as morally praiseworthy unless one is engaged . . . in promoting flourishing of an inclusive social collectivity” (p. 31). For Koggel (2002), professional and personal relationships create interactions important for self-development and autonomy and necessary for promoting equality and reducing oppression; her concerns relate as well to human dignity and worth.

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Buber’s construction of the dialogic “I–Thou” is among the most compelling. While acknowledging the rarity of this type of relationship, he explains that people and their interpersonal relationships allow for individual responsibility (akin to Appiah and Aristotle in eudaimonia): “man becomes an I through a You” (Buber, 1970, p. 80); “knowledge of oneself is inherently knowledge of self in relation to others” (p. 61). The ethical principle “Social workers recognize the central importance of human relationships” is elaborated as “Social workers understand that relationships between and among people are an important vehicle for change. Social workers engage people as partners in the helping process. Social workers seek to strengthen relationships among people in a purposeful effort to promote, restore, maintain, and enhance the well-being of individuals, families, social groups, organizations, and communities” (NASW, 2008 [1996], p. 6).

manner consistent with them. Social workers act honestly and responsibly and promote ethical practices on the part of the organizations with which they are affiliated” (NASW, 2008 [1996], p. 6). This is discussed further in Standard 3.09, Commitments to Employers, “(d) Social workers should not allow an employing organization’s policies, procedures, regulations, or administrative orders to interfere with their ethical practice of social work” and “should take reasonable steps to ensure that their employing organizations’ practices are consistent with the NASW Code of Ethics” (p. 21). The IFSW states in item no. 3 of the professional conduct principle #5, “Social workers should act with integrity. This includes not abusing the relationship of trust with the people using their services, recognising the boundaries between personal and professional life, and not abusing their position for personal benefit or gain” (IFSW & IASSW, 2004, pp. 3–4).

Integrity Referring to character, trustworthiness, honesty, and commitment to ethical behavior, the integrity of professionals is especially important in that the public turns to the professions for expertise and trusts them with highly personal matters, at times determining life or death.

Pritchard (2007) emphasizes its increasing importance as professional behavior becomes more highly specialized and difficult to evaluate by those outside the professional group. To practice with integrity, social workers must have knowledge about the profession’s mission and values and must rely on the ethical code to guide practice decisions. It is this value of integrity that directly captures the accountability of social workers to the profession’s value base while acknowledging the potential conflicts they may encounter. The ethical principle “Social workers behave in a trustworthy manner” is elaborated as “Social workers are continually aware of the profession’s mission, values, ethical principles, and ethical standards and practice in a

Competence Defined as reaching a specified level of proficiency and expertise, competence is important at all levels of education, in most areas of employment, and especially by professional occupations.

Increasing emphasis on goal attainment and outcome measures has accompanied demands by insurance and state and federal guidelines to reach certain levels of competence for payment of services. Additionally, accrediting groups responsible for setting educational and performance standards and professional groups responsible for oversight to ensure ethical practice seek clarity of criteria for competence. Trust in the professional’s competence has traditionally provided the basis for clients conceding a “monopoly of judgment,” that is, trusting that the professional knows better what is wrong and how to fix it. Social workers acquire and stay current with knowledge developments and provide services based on their expertise even though their roles and areas of knowledge/ skills may differ within the same setting.

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The ethical principle “Social workers practice within their areas of competence and develop and enhance their professional expertise” is elaborated as “Social workers continually strive to increase their professional knowledge and skills and to apply them in practice. Social workers should aspire to contribute to the knowledge base of the profession” (NASW, 2008 [1996], p. 6). In Standard 1.04, “(a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience” (p. 8). Additionally, Standard 2.05, Consultation, “(a) Social workers should seek the advice and counsel of colleagues whenever such consultation is in the best interests of clients” (p. 16). Under its Principle 5.6, the IFSW states, “Social workers have a duty to take necessary steps to care for themselves professionally and personally in the workplace and in society, in order to ensure that they are able to provide appropriate services” (IFSW & IASSW, 2004, p. 4). Social Work Ethics From a historical perspective, ethical codes are relatively recent. Although there were draft codes during social work’s early years, it was not until 1947 that the American Association of Social Workers (AASW) adopted the first formal code, and 5 years after its founding the NASW adopted its code, which has since been changed many times. Initially similar to the current IFSW code, it was one page in length, with 14 brief, first-person statements directly stating what social workers should do, such as: every social worker’s duty is to give priority to professional responsibility (Johnson, 1955). Currently, the NASW code has 22 pages with many explanatory paragraphs and qualifiers. Drawing from the abstract values for what the profession deems desirable, ethics provide guidelines for the right practice behaviors that accomplish the changes toward what is good and desirable.

Globalization has increased movement of professionals across borders, raising questions about the legitimacy of practice knowledge and behaviors and ethical codes designed in a different social context. Furthermore, laws and regulations may supersede the ethical guidelines and norms accepted by particular groups or society at large may also contradict the ethical codes. For social work, 100 member organizations representing about 90 nations are listed as members of the IFSW (2014). Although they tend to share the primary values of social justice and human well-being, the meaning they attribute to these concepts may vary. Furthermore, each nation usually has its own code reflective of that country’s culture and values resulting in varying meanings and applicability of the ethical standards. Hugman (2008) points to the difficulties of shared ethics among very different nationstates and cultures, and Healy (2007) argues for a “mid-range” stance of the relativism–universalist continuum, which would acknowledge the importance of human rights for equality and protection while also recognizing the importance of diverse cultures. Views about ethics and morality have long been the province of philosophers. The universal (deontological) view is credited to Kant (1785), one of the major philosophers of Western thought, who argued that moral agency required morals based in reason and rationality. His categorical imperative, although debated since the 1700s, holds that each person has reason and therefore has worth and deserves respect. This is in contrast to consequentialist or utilitarian ethics, which focuses on the outcomes for people—where is the greatest harm and for how many persons? This school of thought was founded by Mill (1863 [1957]), a British philosopher and economist influenced by empirical thought—relying more on evidence than universal principles. Further discussion follows later in this chapter’s sections on human rights and ethical reasoning, affirming that these opposing perspectives remain and will continue to be part of an

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ongoing discourse for ethical decision making across cultures and nation-states. Ethical Standards Explanations of self-determination, confidentiality/privacy, informed consent, and duty to warn/protect followed by case studies will illustrate how they are integrally connected, sometimes contradictory and at other times dependent on each other. They all fall under Standard 1, Social Worker’s Ethical Responsibility to Clients. Excerpts are cited from the NASW code (2008 [1996], pp. 7–15). After full discussions of these standards, case studies illustrate their use in practice. STANDARD 1.02: SELF-DETERMINATION

Social workers respect and promote the right of clients to self-determination and assist clients in their efforts to identify and clarify their goals. Social workers may limit clients’ right to selfdetermination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.

And from Standard 1.08, Access to Records: “(a) Social workers should provide clients with reasonable access to records concerning the clients.” Although self-determination has long been viewed as central to social work, it is not always easy for practitioners to incorporate this ambiguous concept into their practice with clients. The Social Work Dictionary definition states that it “recognizes the rights and needs of all clients to be free to make their own choices and decisions. Inherent . . . is the requirement for the social worker to help the client know what the resources and choices are and . . . the consequences” (Barker, 2003, p. 387). Implying self-mastery or autonomy over one’s actions, self-determination is a client right as well as a social work value and responsibility. As a right, it is fundamental to democratic societies and forms the basis for

additional rights and privileges including confidentiality and privacy. As a social work ethic, it is directly related to the “supreme value” of the social work profession, the innate dignity and value of the individual (Dolgoff, Loewenberg, & Harrington, 2005). Dworkin, who writes about autonomy, suggests there is an intrinsic value “to being able to make choices.” What makes an individual particular is this self-determination, the “construction of meaning in his life. . . . It is because other persons are creators of their own lives . . . that their interests must be taken into account, their rights protected” (1988, p. 110). There are challenges in practicing client selfdetermination. One directly relates to the person in environment perspective. Often, clients seen by social workers have basic needs for food, shelter, employment, medical care, and safety from physical harm. Choice and autonomy may not be feasible when basic needs are lacking, compromising self-determination. Social workers’ attention to basic needs honors self-determination. A second challenge is the paradox between practicing selfdetermination and functioning as change agents. In this latter role, social workers actively seek to make something different from what it was, yet this may directly conflict with the client’s own choices.

Balancing the act of offering expert help with respect for a client’s autonomy remains a challenge for every practicing social worker. As Helen Harris Perlman (1965) states, this goal may be illusory: “Self-determination is nine-tenths illusion, one-tenth reality . . . but as . . . one of the ‘grand illusions’ basic to human development and human dignity and human freedom I am committed to supporting it” (p. 410). Taylor (2006) indicates seasoned social workers still consider self-determination as “very important” to their practice. While illness or other situations may limit independence which in turn limits autonomy, social workers must exhibit respect for clients as individuals with free will and a right to self-determination as primary and at the same time accept their role as changeagents.

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Acknowledging this basic contradiction will help social workers struggle anew with the meaning of this core concept each time they relate to clients. From a political science perspective, Drake (2005) considers self-determination theory as a means of understanding human development and the basic needs of individuals to have choice and control over their lives. Deegan (1996) draws from her personal and professional experiences in discussing the importance of self-determination in rehabilitation. Citing the philosopher Heidegger, she exhorts practitioners to respect the uniqueness of all humans in explaining “the goal of the recovery process is not to become normal. The goal is to embrace our human vocation of becoming more deeply, more fully human” (p. 92). STANDARD 1.03: INFORMED CONSENT

In instances (b) when clients are not literate or have difficulty understanding the primary language used . . . , social workers should take steps to ensure clients’ comprehension. (c) When clients lack the capacity to provide informed consent, social workers should protect clients’ interests by seeking permission from an appropriate third party, . . . and . . . should take reasonable steps to enhance such clients’ ability to give informed consent. (d) When clients are receiving services involuntarily, social workers should provide information about the nature and extent of services and about the extent of clients’ right to refuse service.

And from Standard 1.07, Privacy and Confidentiality: “(d) Social workers should inform clients, to the extent possible, about the disclosure of confidential information and the potential consequences, when feasible before the disclosure is made. This applies whether social workers disclose confidential information on the basis of a legal requirement or client consent”(p. 10).

Informed consent forms the basis for selfdetermination. Treating clients as autonomous individuals requires those clients to be informed and knowledgeable. Social workers are responsible to inform their clients of the nature and course of any planned treatment. Without informed consent, client self-determination is impossible; autonomy requires availability of information in order for clients to make choices.

As Dworkin explains his views of an intrinsic right to make choices, “consent preserves the autonomy of the individual because his right to self-determination, his control of his body and his possessions, can be abrogated only with his agreement” (1988, p. 90). Philosophers have long been interested in autonomy (Appiah, 2008; Berlin, 1984 [1969]; Rawls, 1971), recognizing that democracies require citizens who are independent moral agents. Codes of practice reference self-determination and empowerment as the ethical basis for informed consent (Bisman & Hardcastle, 1999). Beauchamp and Childress (1994) offer a medical perspective finding that “veracity” is at times lacking in medical care, and Clark (2000) includes honesty and truthfulness as one of his rules for ethical social work practice: “social work services should be . . . truthful and transparent to users” (p. 51). Similar to other ethical guidelines, informed consent is not as simple and direct in practice as it is in theory. When it is necessary to constrain self-determination, such as civil commitment wherein there is a danger to self or others or incarceration with violation of laws, informed consent protects autonomy. Some situations (such as mental impairment or minors) may require someone to act in the place of these individuals who are not able to (or should not) provide consent. Therefore, the proxy must seek to understand the individual’s best interests and wishes despite a possible lack of clear criteria and authority, placing great responsibility on the representation. On occasions where no trustee is available, the professional may

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assume the role of trustee; here it is critical to resist behaviors that will reduce informed consent and self-determination (despite a potential agency rebuke) if it is not clear that the client is truly unable to be informed enough to consent. Reamer advises minimal use of proxy consent to protect as much as possible autonomy of both professional and client. His guidelines offer clarity: no coercion or undue influence; capacity to provide consent (above a certain age, not diagnosed with dementia are some provisos); limited consent for specific procedures; valid consent forms; the right to withdraw or refuse consent; adequate information to reach a decision (Reamer, 2001). In drawing from a number of research studies, Appelbaum, Lidz, and Meisel (1987) stress that ethical decision making should involve both medical and legal perspectives when dealing with clients whose capacities for decision making may be impaired. Criteria for determining impairment and protocols for obtaining data should inform such decisions; education and treatment approaches to improve cognitive capacity could help to facilitate consent that is informed. Colvin, Nelson, and Cronin (2012) advocate integrating social workers into medical–legal partnerships (MLPs) for comprehensive problem-solving. While acknowledging the different obligations among these professions stemming from their values and ethical codes, they consider such collaborative work beneficial for effective services. Again, similar to the practice of selfdetermination, there are inherent limits to informed consent, requiring assiduous attention by social workers to practice the spirit and intent of these complex ethical standards. Written consent from clients before sharing their information, information about their treatment, and access to their records reflects informed consent and also promotes self-determination. Practicing informed consent requires advising clients of one’s status and experience. This may involve information about education and background, particular areas of expertise and theoretical frameworks; it

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should also include that sharing occurs with one’s supervisor and other colleagues at the setting (Bisman, 2008b). Along these lines, one’s identification as a student or intern should occur early in the relationship. As well as being honest and in accord with the profession’s ethical code (note Section 4.06, “c. social workers should claim only those relevant professional credentials they actually possess and take steps to correct any inaccuracies or misrepresentations of their credentials by others”; NASW, 2008 [1996]), this early discussion can free students from undue guilty feelings at semester break or at the termination of the placement. STANDARD 1.07: PRIVACY AND CONFIDENTIALITY

(a) Social workers should respect clients’ right to privacy. Social workers should not solicit private information from clients unless it is essential to providing services or conducting social work evaluation or research. Once private information is shared, standards of confidentiality apply. (e) Should discuss with clients and other interested parties the nature of confidentiality and limitations of clients’ right to confidentiality. Social workers should review with clients circumstances where confidential information may be requested and where disclosure of confidential information may be legally required. This discussion should occur as soon as possible in the social worker client relationship and as needed throughout the course of the relationship. (f) When counseling services to families, couples, or groups, social workers should seek agreement among the parties involved concerning each individual’s right to confidentiality and obligation to preserve the confidentiality of information shared by others. Social workers should inform participants in family, couples, or group counseling that social workers cannot guarantee that all participants will honor such agreements. (h) Social workers should not disclose confidential information to third party payers unless clients have authorized such disclosure.

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(i) Social workers should not discuss confidential information in any setting unless privacy can be ensured. Social workers should not discuss confidential information in public or semipublic areas such as hallways, waiting rooms, elevators, and restaurants. (j) Social workers should protect the confidentiality of clients during legal proceedings to the extent permitted by law. When a court of law or other legally authorized body orders social workers to disclose confidential or privileged information without a client’s consent and such disclosure could cause harm to the client, social workers should request that the court withdraw the order or limit the order as narrowly as possible or maintain the records under seal, unavailable for public inspection. (l) Social workers should protect the confidentiality of clients’ written and electronic records and other sensitive information. (m) Social workers should take precautions to ensure and maintain the confidentiality of information transmitted to other parties. (n) Social workers should transfer or dispose of clients’ records in a manner that protects clients’ confidentiality and is consistent with state statutes governing records and social work licensure. (o) Social workers should take reasonable precautions to protect client confidentiality in the event of the social worker’s termination of practice, incapacitation, or death.

(Note that there are 18 parts to this standard, indicating its complexity and centrality; following are some of the primary issues.) Consistently cited as social work’s guiding principles (and deeply embedded in most professional services), confidentiality and privacy have a long and tense history. Richmond (1917), in the first book written about social work practice (providing social work a method—the social diagnosis), discussed reluctance by those early workers to give the Confidential Exchange private information about their clients in order to

avoid duplication of services (pp. 303–316). The multiple meanings of these terms and increasing court decisions have added further confusion: “Except for the ultimate precept—above all, do no harm—there is probably no ethical value in psychology that is more inculcated than confidentiality. . . . Yet, there is probably no ethical duty more misunderstood” (Bersoff, 2003, p.155). Koggel (2003) offers her philosophical perspective that similar to self-determination, confidentiality promotes autonomy in its facilitating disclosure and self-development. Her concern also includes privacy, which she believes should expand from an individual right to a social right (“access to the personal records of patients who are members of traditionally disadvantaged groups entrenches rather than alleviates inequalities”) and that it is the duty of society to prevent harm of those who are vulnerable (p. 121). Harper (2008) argues for the importance of context including cultural, political, and economic to understand norms around confidentiality. The main issues in confidentiality/privacy are the responsibility of social workers to protect client privacy and to protect and only use information they obtain from clients for professional purposes. As Edwards and Rodrigues (2008) explain, however, “rights to privacy appear to be more readily ignored when transferred into the digital, information society world” (p. 105). The extraordinary challenges of increasing use of social media make it incumbent upon social workers to focus on what they are communicating and to whom. These authors are especially concerned about privacy rights for children and the potential dangers for this population that is not giving consent. McGhee and Clark (2008) believe that the technology explosion may make it impossible to adhere to traditional notions of confidentiality and privacy, yet they point out that these very technologies also allow for greater sharing and open access of information.

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While the social work code of ethics binds social workers to protect confidentiality, legal obligations can require them to provide information in certain situations. Ethical practice that is legal requires that professionals understand this privilege/duty distinction. “Confidentiality as a privilege in the legal sense, may at times belong to the client or the professional—in that either may have the privilege to divulge or not divulge certain details outside of the context of the relationship—whereas a duty to divulge or not divulge is an obligation, albeit a moral as well as a legal one, almost always imposed primarily and sometimes exclusively on the professional, the breaking of which carries moral and legal, as well as practical/functional, consequences” (Bisman, 2008b, p. 23).

Confidentiality provides safety and allows for relinquishing privacy so that the worker can gather data, assess the situation, and provide needed services. Differences among states in the United States and changes at the federal level on privileged communication make it incumbent upon social workers to clarify the regulations in a particular setting. This will help to practice informed consent in advising clients about privacy of notes and records and will protect both worker and client. Just as with self-determination and informed consent, there are some situations where privacy and confidentiality are primary wherein clients should not (even if they have the capacity for informed consent) give up their right to privacy. Duty to Warn or Protect While not itself a principle yet appearing in many parts of the standards, duty to protect is to social work what confidentiality is to the legal profession—significant in social work’s function in society. Standard 1.01, Commitment to Clients, states: “Social workers’ primary responsibility is to promote the wellbeing of clients. In general, clients’ interests are primary. However, social workers’ responsibility to the larger society or specific legal obligations may on limited occasions supersede the loyalty

owed clients, and clients should be so advised” (p. 17). (Examples include when a social worker is required by law to report that a client has abused a child or has threatened to harm self or others.) Standard 1.07, Privacy and Confidentiality, states: “(c) Social workers should protect the confidentiality of all information obtained in the course of professional service, except for compelling professional reasons. The general expectation that social workers will keep information confidential does not apply when disclosure is necessary to prevent serious, foreseeable, and imminent harm to a client or other identifiable person. In all instances, social workers should disclose the least amount of confidential information necessary to achieve the desired purpose; only information that is directly relevant to the purpose for which the disclosure is made should be revealed.” And from the previously discussed Standard 1.02, Self-Determination: “Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.” The complicated interactions among the ethical principles can cause confusion and conflicts for practitioners. While duty to warn/ protect supersedes confidentiality/privacy and self-determination, Banks (2006) points out, “self-determination is not an absolute moral principle, . . . therefore it can be morally right to go against” it, based on the worker’s judgment (p. 175). For her, acting with moral integrity requires that social workers think through all “aspects of the dilemma and make a decision to act in order to try to avoid the worst outcome” (p. 25). Court decisions have established that when the client threatens harmful or criminal acts, the “duty to warn” supersedes the protection of a “privileged communication.” One of the more famous and still influential is Tarasoff v. Regents of the University of California (1976), where a clinician warned the police that his patient

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threatened to kill a young woman. The murder occurred (the patient was released after questioning by the police), and the murdered woman’s parents sued the clinician’s employer. The California Supreme Court ruled that the clinician should have warned the woman herself. In a more recent case, Emerich v. Philadelphia Center for Human Development (1998), the mental health professional did warn the young woman whom his client threatened to kill and gave her advice to protect herself but did not contact the police. Here again the client killed the woman, and the professional was sued for negligence in not notifying the police. The Pennsylvania Supreme Court adhered to the Tarasoff (1976) ruling affirming that in warning the woman, the professional was in fact “not guilty” of negligence. These cases reflect duty to both warn and protect guided by a social responsibility to “do no harm” and therefore having to protect a person other than the client from possible harm. Social workers frequently practice with situations that require duty to warn over confidentiality. Domestic violence, child and sexual abuse, suicide and abuse of the elderly are just some of the many situations that may call on the duty to inform or protect persons at risk of harm.

Another situation is when clients refuse to disclose the presence of AIDS to their sexual partner. Legislation exists in some U.S. states that protect these clients’ rights to privacy, emerging in part from the potential discrimination and oppression of persons with this illness. The most high-profile criticisms of social workers have stemmed from failures to protect children from harm. In the United States and United Kingdom, these cases have often occurred through failure to follow procedures, refer for appropriate services, or recognize the existing risk in the assessment and intervention. DePanfilis (2003) points out that in many such failures, signs of repeated abuse were ignored by the assigned workers; this is confirmed by Rzepnicki and Johnson (2005) in a later study. Harm may also occur by not exposing poor

practices in an agency (such as group home abuse, corrupt or harmful practices). Gambrill (2005) calls on critical thinking skills and use of evidence to increase the helping and reduce these harmful (and alarmingly frequent) situations. While some sources providing ethical guidelines are cited later in this chapter, we repeat here that social workers must be knowledgeable about agency practices and state/federal regulations for duty to warn and protect. In all cases, informed consent is essential; clarity with clients about the limits on their confidentiality and privacy is fundamental to client self-determination. Mill’s (1859) important work On Liberty addresses this critical value: the “sole end . . . in interfering with liberty . . . is self-protection . . . the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others” (p. 223). Summary Guidelines for Ethical Reasoning Differences in social workers’ handling of ethical dilemmas exist and may relate to both personal and professional demographic factors (Lynch, 2010). Spano and Koenig (2007) argue that social workers should rely on the NASW code and not on their personal worldviews in order to avoid conflicts between personal beliefs and professional ethical practice. Reamer (1999, pp. 72–75) provides clear guidelines for prioritizing ethical decision making and also suggests an ethics audit to monitor and manage risk (2005). Dolgoff et al. (2005, pp. 59–60) advise practitioners to draw from the ethical code, monitor and evaluate and use ethical screens to minimize conflicts between the rights of individual clients and the larger society. Taylor (2007) discusses professional dissonance as, “a feeling of discomfort arising from the conflict between professional values and job tasks,” is a necessary albeit not sufficient prerequisite to help practitioners develop awareness of conflicts and thereby initiate ethical reasoning. Such awareness can facilitate dialogue and

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values clarification within the work setting and lead to innovative practice and policy interventions. The tension from such continuous monitoring can increase the sense of safety for workers and reduce anxiety (pp. 89–90). Banks (2006) offers guidance in distinguishing between dilemmas and ethical problems. For her, an ethical problem is “when the social worker sees the situation as involving a difficult moral decision, but is clear what is the right course of action” (pp. 12–13). She defines an ethical dilemma as occurring “when the social worker sees herself as facing a choice between two equally unwelcome alternatives, which may involve a conflict of moral values, and it is not clear which choice will be the right one” (p. 13). Bilot and Peluso (2009) suggest use of genograms (a tool to explore family dynamics and history, discussed in chapter 4) to help social workers explore how their ethical development and ideas have been shaped by their own family of origin. Informed by the above authors, the following points provide guidance in ethical decision making. 1. Identify the ethical challenges including potential ethical consequences of your decision on individuals, communities, and organizations. Remember that one cannot be self-determining at the expense of another’s life or property. Yet, if someone wants to be homeless or go on a food fast, they have the right to do so as long as they are not adjudicated incompetent or irrational. An individual’s right to basic well-being takes precedence over another individual’s right to self-determination (to do the other harm). 2. Draw knowledge from relevant ethical theories, principles, and guidelines; codes of ethics and legal principles; and social work practice theory. Be informed about the specific duty to warn and protect statutes and practices of your country/state/agency. 3. Pay attention to and reflect on your personal values; they must not substitute for the professional codes of ethics (discussed fully in chapter 7).

4. Be a critical thinker, reflect on what you are thinking and doing. Obtain feedback in consultation with colleagues and other experts and especially with your supervisor. 5. Consider whether you are experiencing professional dissonance—identify any discomfort around conflicts between professional values and job tasks. When you accept employment with an organization, you are obligated to follow its regulations unless the rules are harmful to the well-being of others (in which case you should advocate for a change; with egregious behavior it may be necessary to “go outside the system”). 6. Maintain records about content and articulate your process of ethical decision making. 7. Continually evaluate what is happening and be open to changing your approach. We now pick up with Ellen from chapter 2, followed by other cases that illustrate practice in which the social workers use different approaches, showing how conflicts between the ethical standards defy simple rules to guide practice and how these social workers engage in ethical reasoning.1 CASE STUDY: ELLEN AND JANE—CONFLICTS BETWEEN CONFIDENTIALITY AND DUTY TO PROTECT AND THE PRACTICE OF SELFDETERMINATION AND INFORMED CONSENT

In the previous chapter, Ellen was struggling to clarify her role and identity as a social worker. At this point, she has been seeing her client Jane on a weekly basis for 3 months. Jane is 32 years old and has a history of inpatient and outpatient treatment, including treatment for homicidal and suicidal attempts. Employed as a licensed practical nurse, 1. Locales for the case studies presented in this chapter could include Alexandria, VA; Brooklyn, NY; Cardiff, Wales; Camden, NJ; Durham, England; Edinburgh, Scotland; Kansas City, KS; Luton, England; Newark, DE; Newark, NJ; New York, NY; Oxford, England; Philadelphia, PA; Queens, NY; Teesdale, England; Topeka, KS; Washington, DC; Wichita, KS.

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she has been socially isolated but is now planning to marry John in 1 month. He owns a small family farm in this rural midwestern area of the United States. (This case draws from a case in Bisman, 1994. It is also discussed in chapters 4–8.) Ellen: Tell me how things have been going this week. Jane: I’ve been sleeping more. Ellen: Tell me more about the sleeping. Jane: I get myself to work and do all right when I’m at the hospital. But when I’m home, I mostly sleep. Ellen: What has John had to say about your sleeping? How is it affecting your time together? Jane: He’s busy on the farm, and with my working night shift, he hasn’t really noticed that anything is different. Ellen: What does the increase in sleep mean to you? Jane: That I’m getting depressed. Ellen: What are other indications of you being depressed? Jane: [A very long pause] Well, I’ve been feeling like hurting myself. Ellen: What do you mean, specifically? Jane: I’ve taken home one of the surgical knives from the hospital. It’s very sharp and I’ve considered using it to cut my wrists. Ellen: I am glad you are sharing this with me. You have told me in previous sessions that at various times in your life you have had these feelings. What do you think is going on now that you are considering killing yourself? Jane: I’m not sure. [Showing her wrists which have scars of previous cuts] I have hurt myself in the past. Ellen: Yes, I know from your records, which you and I discussed, and also from our conversations. How bad are these feelings? Jane: Oh, I don’t like feeling like this, but I can handle it. Ellen: Perhaps you need to enter the hospital as an inpatient? What do you think? Jane: No, I don’t want to become an inpatient. I have had this worse in the past. Ellen: If you do not want to enter the hospital for a few days, I ask you to make an agreement

with me that will involve several things—make a contract with me that you will not try to kill or harm yourself; and if you have those feelings you will call me, or anyone on duty on the inpatient ward or the outpatient unit. I also ask that you call Dr. Strauss to discuss whether you need an increase in your medication. Jane: [Long silence] I will agree to those things. I was thinking about taking more medicine, but I don’t like the side effects—I have trouble keeping off those extra pounds, have to use so much sunscreen and it even upsets my stomach. Ellen: I know that there are unpleasant reactions to more medicine, but it is important to consult with Dr. Strauss. And as we have discussed before, I too will talk with him and the other team members and update them on what is happening. Now today is Wednesday, I’d like to schedule an extra appointment for Friday for the two of us. I also ask that you bring in that surgical knife or return it to where you took it from. How does that sound to you? Jane: Yes, I can come in on Friday. It will be good to see you before the weekend. Why do you want me to bring the knife in? Ellen: It would symbolize your agreement to this contract, and I would feel more comfortable that you won’t harm yourself with it. Jane: [Long silence] Okay, I’ll bring the knife in on Friday. Ellen: Now let’s talk some about your next two days. Tell me how you will be spending your time between now and Friday? Ellen comments on her practice of duty to protect, informed consent, and self-determination: I quickly scheduled time to talk with my supervisor for support and feedback about my approach and to also schedule a team meeting to inform others about what was happening. In our very early sessions, the topic of suicide had come up and of course I read about Jane’s various (serious) suicide and homicide attempts. I became anxious and even fearful and decided with my supervisor (and consent from Jane) to videotape our sessions. This not only helped reduce my anxiety

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(I could review them with my supervisor) but also reduced my fear and gave me a greater sense of safety. With the help of the team members and my supervisor, I became more comfortable in honoring Jane’s self-determination while also practicing duty to protect. Jane had struggled for many years to reach her current level of independence; she was now living on her own, employed in a responsible position, and committing herself to a marital relationship. These behaviors warranted respectful treatment as a competent adult individual. Infantilizing Jane by telling her she needed inpatient treatment could undo much of the progress made over these years. All of this work on my approach with Jane and on my feelings and the profession’s values helped me to practice self-determination; I acknowledged the seriousness of her current situation in asking her whether she needed to be hospitalized and treated her respectfully in negotiating a suicide contract (practicing informed consent). On Friday, Ellen and Jane had the following exchange: Ellen: I want to thank you for bringing the knife in. Tell me about your past two days. Jane: I worked both nights, and then, as we talked about on Wednesday, I scheduled myself for some errands in the afternoons. I set several alarms and radios around the house so I would be sure to get up. I managed all right and didn’t need to call anyone. Ellen: What about your medication? Jane: I didn’t call Dr. Strauss, I decided I didn’t need to do that right now. The wedding is coming up in a few weeks, and I don’t want to be increasing my dosage. Ellen: What is your thinking about that? Jane: Well, taking more medicine would mean I’m getting sick again, and I don’t want to think that. Ellen: I see. You know, I have trouble with my stomach, and there are various times I need to take medication to help me. I’m not always sure why it starts up at a particular time, but I do know that when it does I need the help of

the medicine. It’s usually time-limited for me and I think that has been your experience, if I am remembering correctly? I know you also have worried about long-term effects of being on these powerful drugs, and data do support your concerns about long-term use of them. Consider getting that help if you need it now with a prompt return to a lower dosage once you are feeling more stable. Jane: You’re right, it has happened where I have to take extra dosages but then can cut back again. Ellen: This has got to be a very stressful time for you. Getting married, making that kind of commitment to someone, and facing that big wedding with your relatives coming and staying for a few days. How are you doing with all of that? Jane: I was just thinking that the other night [hesitantly], maybe I’m not ready for all of this just yet. Ellen: You know, there are other ways to get out of the marriage than getting sick again and needing to go back in the hospital or killing yourself. Jane: [Chuckles and then laughs] I know. I love John and I want to go on with my life, have children and my own family. I’m probably as ready as I’ll ever be. Ellen: [Smiles and laughs too] Probably so, and it is not unusual to have second thoughts about such a major life change. I also want you to know that I have talked with Dr. Strauss and other members of the outpatient team, they are available should you want to contact them. Throughout the interaction, one can see that Ellen behaves with competence and integrity and treats Jane as someone with dignity and worth. Able to talk together about Jane’s thoughts of suicide, they agreed on a reasonable course of action for safety. Ellen also practices informed consent by letting Jane know she has talked with the team. Ellen comments again on self-determination: I began to realize how fundamental the ethic of self-determination was to the practice of social

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work. This was caring about people enough to let them make their own choices, to educate them and coach them so they could handle their freedom of choice with responsibility and competence. My instinct was to take control and make Jane safe in the hospital, yet of course, I knew that being an inpatient was not a full life. Jane had already had many years of that and was now opting for the real world, which involved dealing with life’s challenges. I knew it was important for me to learn to not have people emotionally dependent on me or I would have a very hard time being effective at this work and probably wouldn’t last very long because my own emotional state would begin to crumble. Yet even more critical is the ethical proviso of selfdetermination—one of the premier values of the profession and one I knew must guide my practice except for very clear circumstances of harm. Duty to protect Jane was at this point not the primary issue. We all took steps to practice duty to protect and at the same time emphasized her self-determination and empowerment to live a fully functioning life with managing her schizophrenia. I did talk with Dr. Strauss, the medical head of the team. He agreed that Jane needed to call him if she wanted to discuss a change in medication and concurred that there can be neurologic side effects from lifetime use of neuroleptic medications (Kelly, 2005). I also tried to stay informed about new developments such as research showing an impoverishment of prefrontal dopamine may contribute to schizophrenia with dopamine offering good results for some (Angier, 2009). It was clear that medications were a significant aspect of Jane’s treatment. Ellen’s interactions demonstrate ethical practice by regularly informing her client and engaging a team approach allows for client self-determination and treatment with human dignity and respect. This case will continue in chapters 4–8. YYY

CASE STUDY: CARMEN AND LISETTE—CONFLICTS BETWEEN CONFIDENTIALITY AND DUTY TO PROTECT AND THE PRACTICE OF SELFDETERMINATION AND INFORMED CONSENT

Carmen’s practice with Lisette and her family starts with attention to some of the inherent conflicts in adherence to these ethical standards. We will pick up on this case later in chapter 7. I have not been much of a political activist and came into social work to practice with children and families. In the foundation courses I learned about advocacy and empowerment, poverty and social justice, and the impact of policies on the lives of people, and I started to think differently about my life and my career in this profession. For my final-year field placement, I ended up in an agency to help meet the needs of newly arriving immigrants. Of course, many different groups came for our services, especially the free legal help, and although most were from Latin America, people from Africa and Asian nations also showed up. Sixteen-year-old Lisette Herreras raised concerns for me. Accompanying her parents and 14-year-old brother to the visits, she hardly spoke and kept her head down. They had arrived from Mexico 3 years before, which would have been a difficult age for her to make adjustments to a new country and new school. There was some extended family in this area, but I feared Lisette might be finding it hard to make friends. Moreover, the parents were still struggling in finding steady employment. The parents worried about the son getting involved with a gang, yet couldn’t keep him in the house all the time. And Lisette reminded me of myself. At her age, I was getting excited about applying to college, and here she was seemingly without any plans for herself. I asked both the parents and Lisette if I could meet alone with Lisette, and they all agreed. Carmen: I am now going to ask you some questions, and it’s important that you answer honestly. If I have concern for your safety, I will have to

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share what you say with your mother and other staff members. Some of the questions have a yes or no answer, but I hope you will describe your feelings to me so that I can better help. First, please tell me how things have been going for you since your move to the United States. I know it was 3 years ago and imagine this has not been an easy adjustment for you. Lisette: You are right, I have become more sad ever since the move. Carmen: Tell me what you mean by sad. Lisette: I don’t like myself, feel like crying, no one here likes me. In a mental status assessment for suicide risk, it is necessary to ask particular questions, so in addition to open-ended questions there are a number that are closed-ended resulting in simple yes or no (these will be discussed in detail in chapter 6). Note Carmen’s immediate practice of informed consent in letting Lisette know she would be sharing information of concern with the mother and staff if safety became an issue. Carmen: Are you feeling like hurting yourself? Lisette: Yes. Carmen: Have you thought about how what you would do? Lisette: Yes. Carmen: How would you do it? Describe your plan. Lisette: Well, I saw this movie where the girl took too many pills. I tried this last year but I just threw up. I then thought of jumping off of an overpass over the highway in front of a tractortrailer. I am sure that would work. Carmen: Do you plan on doing this? Lisette: I don’t know, I’d rather just not feel so sad. Carmen: I’d like to get some more information. Talk about how well you have been sleeping? Lisette: I’m not sleeping. I lay there most of the night. I may fall asleep, but it is not for very long. Carmen: What is going on in your mind when you are not sleeping? Lisette: I think about a lot of things. How nobody likes me at school. I’m a waste. It just goes on and on.

Carmen: How long has this been going on? Lisette: For about a month. Carmen: Talk about things you enjoy doing. Lisette: Oh, I like music. I wish I could be back home in Mexico, I miss the dancing and music. Carmen: Is there anything else you might want to tell me or think I should know? Lisette: No. Carmen: I want to let you know that I am very concerned about what you said about hurting yourself. Let’s bring your parents in so we can all talk together. Carmen believed that in order to practice duty to protect, she needed to gather information for decision making about Lisette’s mental status and potential risk for suicide. Unlike the previous exchange between Ellen and Jane, the professional relationship had not yet been established, making this more challenging. Carmen was not always asking open-ended questions because she was looking for affirmative or negative responses to assess quickly this client’s suicide risk; and she began seriously considering that Lisette was at risk and in need of hospitalization. The following exchange took place between Carmen, Lisette, and her parents. Carmen: Mrs. H, I’m very concerned about your daughter. She is talking about hurting herself, seems overcome with sad feelings, thoughts of suicide, and has a specific plan. I am thinking of recommending hospitalization for her. Mrs. Herreras: We can’t do that, we have no health insurance and no legal residency here. Can’t you help her? Carmen: Has anyone else in the family attempted or committed suicide? Mrs. Herreras: No, her grandfather was mentally unstable, but nothing like this. Carmen: [Said directly to Lisette] Has there been sexual abuse? Lisette: No. In this situation, unlike Jane in the previous example, there are limits to Lisette’s self-determination due to her age and higher risk. We previously

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discussed Standard 1.02 of the NASW code (NASW, 2008 [1996]): “Social workers may limit clients’ right to self-determination when, in the social workers’ professional judgment, clients’ actions or potential actions pose a serious, foreseeable, and imminent risk to themselves or others.” Because Lisette is younger and at greater risk of suicide, her parents decided on short-term hospitalization followed by intensive outpatient services. Carmen assisted in managing health care costs.

We again discuss the work of Teresa, whom we met initially in chapter 2. As the project manager for an organization providing services to people with mental health problems, Teresa provides supervision and at times works directly with clients. Here we see her balance duty to warn with the other ethical standards.

few blocks away. Mind you, after his recent arrest and on probation! We have a good health care system in the United Kingdom, so I rushed him into another medical facility connected with us. After a few weeks they gave him a bipolar diagnosis (which made sense) and released him with new medication to help control the mood swings. Now I am very committed to self-determination, but wow, I must now practice duty to protect. To balance these, I help him find a rehabilitation setting that will keep him, it’s gated and out in one of the villages—protects him and others. He agrees. After a few weeks, Stewart is more stable. He returns to the house and he, I, and his attending doctor sit and talk with him. We explain we are morally and legally required to let the coppers know of his arrests and interest in the kids at the primary school.

CASE NARRATIVE: TERESA AND STEWART— CONFLICTS BETWEEN CONFIDENTIALITY AND DUTY TO WARN AND THE PRACTICE OF SELFDETERMINATION AND INFORMED CONSENT

Seven years before Stewart’s stability in a communitybased care setting (discussed in chapter 2), Teresa’s interactions with him directly focused on duty to warn. At this point, he and the roommate with whom he shares a house are both unstable and using drugs. Stewart had been arrested for three attempts at sex with a minor (two 16-year-old males and a 15-yearold female) and spent a week in a 24-hour supervised rehabilitation facility. Well, he gets discharged after the week, and I get assigned to go visit him. I tell him I am here to help him move into good housing and that part of my work involves protecting him as well as protecting others and further explain that if things he says or does involve hurting himself or others, I will have to warn the necessary authorities. At the same time, I say, I will work to protect his privacy, except for the need to protect. He rambled for a while, apologized for the messy house, and then tells me he has been “hanging out” by one of the primary schools a

In advising Stewart of the limits to his confidentiality, Teresa demonstrates her practice of selfdetermination and informed consent, which are then not violated when she informs the authorities of her concerns. Mandated to warn others for their protection also helps to protect Stewart from again getting into serious criminal conduct in attempting sexual abuse of a minor. For Teresa, her options were clearer than in Ellen and Carmen’s dilemmas where they needed to carefully consider a range of choices and their possible consequences. When a client’s life is not in jeopardy, one should protect confidentiality and obtain the client’s permission before communicating with others about the client’s situation. Informed consent, however, allows for discussing personal information with the client’s consent. In the case of Lisette, as her legal guardians, her parents are responsible for decisions, requiring Carmen to include them in discussions of options. Informed consent also requires providing knowledge necessary for informed decisions such as effects of medications, consequences of hospitalization, success rates for treatment of depressions, and so forth. The lack of citizenship and health insurance had also to be considered. Carmen and the family agreed that, after a few days as an inpatient, Lisette and she

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would meet twice weekly along with a contract that Lisette would tell her parents immediately if she had feelings to hurt herself. Carmen also gave them a phone contact they could call if there was an urgent situation. They all agreed to this and for a monthly family meeting as well. There are conundrums in the practice of these ethical principles. Would clients share information about committing suicide if they did not want any help? From this perspective perhaps, Lisette was self-determining in talking about her sad feelings as a way of asking for help. This does not abnegate the social worker’s moral obligation carefully to contemplate what the client needs and how to practice ethically. There will be occasions where ethical duty to protect supersedes the ethical standard of self-determination. Many health care settings have institutional ethics committees (IECs) that provide ethical consultation to consider approaches to ethical dilemmas. Some settings schedule regular training sessions or call on experts for staff workshops. As we saw with Teresa, however, once there exists a direct threat by a client against someone else, duty to warn supersedes confidentiality.

These case studies have illustrated the challenges social workers face in adhering to the ethical standards of confidentiality, duty to warn/protect, self-determination, and informed consent. We have seen how ethics emerges from social work’s mission and values and in turn guides the knowledge and skills used by the practitioner. The remaining sections of this chapter will explore the emerging challenges social workers face as they practice with an even greater multitude of differences and cultural norms, consider a range of ethical perspectives, and illustrate practice with a global consciousness and approaches for ethical reasoning. Global in the Local for Ethical Practice Accompanying the increasing interconnectedness across great distances are the especially passionate divisions within and between nations and populations. Globalization challenges social work to expand beyond individuals and

their immediate communities to encompass the wider global society as community. New opportunities for community building and civic engagement on a large scale require a perspective that cuts across ethnic backgrounds and nation-states with relevance domestically as well as globally. Global consciousness is such a framework, and later in this chapter we examine and illustrate how social workers use this new construct to guide practice. We first consider some of the challenges social workers face in sharing ethical perspectives, now made especially difficult by the contemporary demands for incorporating a global perspective into local orientations. Toward the end of the 20th century, international social work perspectives received increasing attention. Healy (2001), Hokenstad and Midgley (1997), and Lyons (1999) are especially noteworthy in shifting the profession’s initially local orientation toward an international orientation (for a full treatment of the historical development of international social work beginning in 1928, see Healy, 2001, p. 6). Jane Addams (1907) was early in recognizing this need; she worked for peace and strengthening of international law, hoping for an internationalism toward greater social morality and peaceful international relations. Now, social workers are practicing globally as 100 member organizations representing about 90 nations are listed as members of the IFSW (2014). Such membership reflects shared commitment to promote social justice and human well-being on an international scale. Papouli’s (2014) analysis of critical incidents (both positive and negative) experienced by students in Greece concludes such research is a valuable source of knowledge and understanding of the development of social work values and ethics in professional practice. A study by Weiss (2005) offers some promise in its findings of a common core shared by social workers across 10 different countries representing diverse cultural and social contexts. Nevertheless, the response has been slow among the largest group of social workers,

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those based in the United States, to acknowledge responsibility to persons beyond their national borders, and problems remain in translating knowledge and skills to meet global and ethical challenges. Moreover, serious gaps seem evident in ethical practice by social workers. Participants in an Israeli study acknowledged that although promoting social justice was an important aim, it was in fact their least attained; the highest was enhancing individuals’ inner resources, followed by protecting people at risk. These social workers viewed community development and policy practice as somewhat lower modes of practice. Such findings indicate that, ideologically, workers value the duality of individual and society, but don’t necessarily practice it (Weiss-Gal, 2008). Taylor’s (2006) research supports these concerns in its indication of a worrying trend toward weakening change efforts in the environments where clients live. In their study of Canadian social workers, Johns and Crockwell (2009) found a growing perception that the ethical code was not as central to practitioners as organizational policies and procedures as well as a perceived conflict between the code and legal requirements. Although access to the code was considered important, participants indicated feeling more “managed” than “clinically supervised” and identified barriers to upholding ethical principles such as workplace policies, the changing nature of practice, insufficient time to reflect critically on the ethics, and heavy workloads. While embracing a global society, actions may still target seemingly local troubles. Lyons (2006) explores how local practice affects global issues. Sewpaul (2006) believes that social work can bridge this local/global gap: “The problems experienced by people with whom we work are, in large measure, linked to structural sources of oppression, exclusion, and poverty at the global level, and if we are to seek adequate solutions, we need to engage with global structural forces” (p. 430). Jansson (2008) urges policy advocacy that crosses international boundaries to help vulnerable populations made more so by some of

the negative effects of globalization such as job losses and economic stagnation. Pollack (2007) discusses the growing importance of international law, which he defines as “principles which govern the relationships of nations with each other” derived from both conventional (treaties) and customary (sense of obligation) law (p. 420). Focusing on disaster relief, he further states that social work’s unique set of skills in building trust and providing direct services is needed as international law expands. While the challenges discussed here are many, the following discussions of ethical perspectives, cultural relativism, and human rights establishes a context that frames practice with a global consciousness and approaches to ethical reasoning. Balancing Sensitivity to Differences and Attention to Human Rights In the section of this chapter dealing with social work ethics, we introduced the conundrum faced by the profession and especially those in practice. The profession’s social justice mission reflects a universalist or deontological view—based as it is on principles of what is right or wrong and what Reamer (2012) calls “duty-based ethics,” associated with Kantian ethics and moral philosophy. Yet social work’s strong ethical commitment to cultural sensitivity and respect for difference can lean toward a consequentialist or teleological view based on what is most beneficial for the greatest number of people, which is associated with Mill; attention here is to context rather than principles. Virtue-based ethics, focusing on character and relationship—what kind of person I want to be and what I owe to others—which is associated with Aristotle, Confucius, Buddhism, and some religions, has received much contemporary attention in its complementing the universalist and consequentialist views while adding the “common good” to what is “good for the individual.” Moreover, its concern with fairness can resonate with a broad range of norms in various parts of the world. Narrative and casebased ethics also fit comfortably in this body

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of thinking with emphasis on rich descriptions by clients of their stories followed by similarly rich explanations by social workers resulting in decision making that is ethical and relevant to the clients’ unique situations. Feminist ethics of care, introduced earlier in this chapter, also draws from virtue ethics to encompass a broad range of ethical issues. These include emphasizing gender justice through fostering empowerment (Kabeer, 2012), considering relationships between gender justice and rights in climate change adaptation (Tschakert & Machado, 2012), and examining the impact of customary practices on gender discrimination in land ownership (Fonjong, Sama-Long, & Fon Fombe, 2012). Levy (2007) believes that social workers can draw from lesbian feminist theory to form support groups and increase support networks “to ensure that women and other non-heterosexual community members encourage and empower each other” (p. 326). Prominent in these virtue ethics approaches is attention to “human capabilities” strongly associated with Sen (1999, 2009). Highly relevant to the NASW definition of social justice and social work’s attention to environments and people, these ideas recognize that choice requires options that are available and feasible. For example, upward mobility in the United States has largely occurred through access to higher education. Such opportunity is decreasing for many populations as costs for undergraduate and graduate degrees continue to skyrocket. Moreover, consideration must also take into account access to good primary and secondary education as well as pre-kindergarten in order for people to have the educational preparation necessary for advanced degrees (and such a discussion could also cover income disparity and problems of poverty such as malnutrition). This model also encompasses attention to people with various disabilities (Johnson, 2013) for whom access may be impossible without policies and services that protect their citizenship rights through expanding options (Hunter & Curtice, 2008).

Cultural Relativism During the 1960s, attention to the many differences social workers must confront in practice with their clients turned specifically to culture. This was especially so in the United States with its movements of civil and women’s rights and War on Poverty, which raised awareness of prejudice within the profession itself and the underrepresentation of clients from groups that were oppressed due to race and ethnicity including African Americans, Latinos, and Asian populations. Pride in different cultural traditions and skin color was important for empowerment and respect. Over these decades, a number of important works not only increased sensitivity to differences but also offered definitions of cultural competence and tools for culturally competent practice (Compton, Galaway, & Cournoyer 2004; Congress & Gonzalez, 2005; Hendricks, 2005, Logan, 1996). Sue and Sue (2003) acknowledge that although this term can imply that such competence is static, they frame it as a journey to increase understanding through self-reflection. Others believe practice requires cultural competence with attention to culture, writ either small or large (Congress, 2005; Hendricks, 2005). Cox et al. (2009) call for use of a cultural consultant to help make sense of a situation from a client’s own cultural perspective. Khaja and Frederick (2008) point out the importance of basic information and ask for reporting of direct data. For example, in discussing a population, they argue for avoiding vague generalities—“80% of the Muslim world is not Arab, and 90% of Arab Americans are Christian” instead of “the Muslim community is very diverse”—to reduce the impact of bias on analysis of information (p. 2). Hall (2007) agrees that social workers require much more understanding of Arab history and culture as does Deepak (2005) in his discussion of parenting and migration. Welbourne, Harrison, and Ford (2007) express concerns about whether practice models can always successfully transition to a new environment. Believing these

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workers may be hampered by lack of linguistic facility, unfamiliarity with regulations and laws, and expectations of their workloads that may not match the reality of a situation, they state that while a “central value base particular to social work transcends cultural boundaries on a universal level, the available evidence suggests that practice itself is very diverse and shaped by local conditions” (p. 31). Some favor indigenization with its concern for local factors over internationalization which they criticize as a one-way direct transfer of Western ideas and practices (Gray, 2010; Tsang & Yan, 2001). Rodenborg & Boison (2013) suggest use of aversive racism and intergroup contact theories to help educational settings reduce prejudice they believe is dominant in a still segregated world. Cultural competence has made significant contributions and continues to be relevant for practice. The work by Congress (2008b) on including culture in family assessments, for example, enhances appreciation by family members of their backgrounds and traditions. At the same time, expansion of the concept to cover explicit knowledge about the many variables that differentiate peoples including ethnicity, race, religion, and culture contains an implicit assumption that members of each group fully share a set of characteristics. Emphasizing such identity politics distracts from a common social welfare orientation with its shared values/ ethics perspective. Walsh (2006) pointedly states, “social workers must realize that it is impossible to ‘know’ another culture” (p. 23); it is also fair to add it is impossible to “know” any culture even deemed as one’s own. Based on their study of patients who are also immigrants, Brämberg and Nyström (2010) add their critique of the categorizing inherent in cultural competence that often privileges culture at the expense of adapting care within the context of each individual’s needs (or addressing issues of class and other important differences). Furthermore, statistics grouped in categories such as census and other data can confuse and

distort the facts. For example, the Asian population in New York City increased 32% over the first decade of the 21st century representing dozens of countries (Asian Indians, Chinese, Filipino, Vietnamese, Korean, and Japanese to name just a few) with more than 40 dialects (Matza & Farrell, 2011). Yet such diversity is not recognized in the broad category “Asian,” and stereotypes continue to perpetuate untruths. The perception that Asians are universally high-achieving and self-sufficient ignores that many Asians live in poverty: the median per capita income for Asians in New York City is below the city’s average, and Asian households are on average more crowded than those of blacks and Hispanics (Semple, 2011, p. A18). Cultural stereotyping and overreliance on clients’ racial or ethnic heritage can make meaningful assessments and effective interventions with each unique client difficult if not impossible. Human Rights Some emphasize the importance of the basic principles of the Geneva Conventions to social work practice in an increasingly global environment (Briskman, 2012; Dominelli, 2007). After the end of World War II, the Universal Declaration of Human Rights (UDHR) by the United Nations General Assembly in 1948 was the first acknowledgment of rights for all humans on a global scale. Involved early in international movements, social workers participated in rights for women and labor as well as world peace. In addition to helping to found the Women’s International League of Peace and Freedom, Jane Addams was involved in many early initiatives, all of which helped to further social work international structures. The first International Conference of Social Work, held in 1928 in Paris, has had monumental influence resulting in the ultimate birth of both the International Federation of Social Workers (IFSW) officially in 1956 and the International Federation of Schools of Social Work (IFSSW) in 1929, both of which retain ties to the United Nations and remain critically important for social work’s

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presence in a global society (Healy, 2001). The IFSW code of ethics was first adopted in 1976, and by the late 1990s it committed to a human rights perspective directly expressed in its definition of social work, which was presented earlier in this chapter. A statement by Tom Johannesen, secretary general of the United Nations during that period, captures the thinking of the IFSW on human rights: “Human rights are inseparable from social work theory, values, ethics, and practice” (1997, p. 155). Reichert (2007) argues that human rights offers the profession a useful perspective for global ethical practice in its view of individual problems as part of a broader set of social issues within an international context. One such example is reframing domestic violence and child abuse from a personal illness or family problem to a human rights issue of violence against women and children. Teaching and learning social work as a human rights profession places the values and ethics in the forefront and draws attention to at-risk populations. She (along with Dominelli [2007] and others) believes human rights should become basic to social work curricula (including the IFSW code). Despite increasing awareness of the international nature of social work services and interests, Ogden (2008) states that American social workers still tend to be relatively uninformed about the basics of international legal instruments and encourages awareness of the Red Cross movement and the services it provides. Skegg (2005) explains that human rights is “a dynamic and evolving concept,” that historically it referred to civil and political rights and has only recently come to focus on cultural, economic, and social issues. Granting that the UDHR currently “carries much weight” because it has the force of treaty law, she also urges caution against universalizing and secularizing and suggests a “globally collaborative and inclusive process” (pp. 667–669). Black (2008) concurs and points out that there are many individuals and populations, especially those already vulnerable such as the elderly, still lacking protection of their rights.

There have been several efforts to find a balance. Banks (2006) acknowledges that scholars in the United Kingdom consider the applicability to social work practice of various forms of utilitarianism with its emphasis on the greatest amount of happiness for the greatest number and also points out that while “rights are an important part of the western liberal tradition in politics and moral philosophy . . . linked to the Kantian notion of respect for persons,” such a view does not fit societies where the individual is not primary (p. 104). Banks also suggests that although it is not possible fully to actualize human rights, they articulate ideals for aspiration . Healy (2007) recognizes that adherents of deontological ethics with its emphasis on fixed moral rules (something is inherently right or wrong) favor the universality of human rights, while those from the teleological school emphasize the context and consequences of ethical decisions and therefore favor the relativist perspective of cultural relevance; she believes both contribute, albeit differently, to the profession. Ife (2007) recognizes the inherent contradictions and challenges for the profession. While acknowledging the power of a human rights perspective for transformational social work, he also points out that “uncritical universalism may lead to colonialist practice, and critical relativism may lead to disempowerment” (p. 77). Briskman (2012) points out disconnections between a welfare needs-based orientation and one focused on rights. Yet agrees that such a paradigm shift could position social work as a leader in developing a rights perspective and imbue social workers with a moral basis for their practice. To summarize the thrust of this discussion: In favoring cultural relativism and its natural focus on cultural competence, there is risk of relying on generalizations about very rich phenomena and engaging in identity politics over community building. At the same time, reliance on a human rights perspective can favor principles over sensitivity to different practices and traditions reducing rather

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than increasing respect for humans. Global consciousness, the new construct introduced in this book and discussed more fully later, suggests ways to incorporate the best of relativism with its sensitivity to diversity and difference yet steer away from simplifications and simultaneously adhere to the moral principles of a human rights approach to confer on social justice the standing given to legal justice.

Advocacy and Empowerment As a central component of social work codes of ethics (BASW, 2002; IFSW & IASSW, 2004; NASW, 2008 [1996]) and inherently connected to self-determination, human dignity and respect, and social justice, the goal of empowerment informs and guides the profession’s practice. Social workers practice advocacy in translating private troubles into public matters, it is a means to an end. In the role of advocate, social workers speak “out on behalf of the client to achieve changes in the conditions that contribute to the client’s problems and securing and protecting a client’s existing right” (Barker, 2003, p. 11). Advocacy is “championing the rights of individuals or communities through direct intervention” (Barker, 2003, p. 11) and is “a cluster of liberatory practices whose goal is to (re)enfranchise epistemically disadvantaged, marginalized, disenfranchised Others” (Code, 2006, p. 165). As Koggel (2007) states, “advocacy emerges from a commitment to knowing well and responsibly, which in turn requires . . . embodied engagement with others, in their lives and in their habitats” (p. 20). She explains the need for two kinds of power. Power-to is “the power that an individual has to attain ends,” while power-with is “a collective ability to act together” (p. 10). Empowerment is “a process of helping individuals, families, groups, and communities increase their personal, interpersonal, socioeconomic, and political strength and develop influence toward improving their circumstances” (Barker, 2003, p. 142) Advocacy is a role central to the practice of social work; empowerment is an expected outcome of the practitioner’s behaviors.

Research by Weiss-Gal and Gal (2009) indicates that participants in an Israeli study attributed little importance to helping clients to realize their rights. The most common type of reported advocacy was informing clients of their rights; less common were activities in which social workers actively advocated by either accompanying clients when applying for benefits or representing them in committee meetings. Papadaki and Papadaki (2008) confirm these results: “social workers did not develop activities in order to improve inadequately resourced services and to challenge agency policies; they tried to find solutions within the constraints they encountered” (p. 163). Findings in Crete, Greece, of McAuliffe and Sudbery (2005) present a more positive picture in that the social workers recognized their ethical dilemmas and experienced frustration with the constraints: “the most common category of ethical dilemmas experienced by social workers arose from conflicts between their obligation to respect clients’ human rights and their responsibilities to the workplace” (p. 164). Respondents identified a range of ethical dilemmas including inadequate resources for clients in poverty; lack of services after hospital discharge; lack of home care for the elderly and minimal funding of residential care for elderly with disabilities therefore necessitating institutional care; organizational rules rejecting protection from harm for children at risk; and problematic regulations around adoption. These authors encourage collective action by social workers for adequate funding and availability of consultation/supervision in ethical decision making. Ethical codes indicate a duty to inform agencies and governments of necessary policy changes: “social workers need to be prepared to question established practices and develop activities to implement change” (p. 178). For some, whistle-blowing is a form of advocacy. Mansbach and Bachner (2009) suggest better coverage in ethics courses with special focus on the abuses of power, while Greene

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and Latting (2004) support integration of advocacy in social work curriculum. Faust (2008b) stresses the need for social workers to assume a more active advocacy role while she acknowledges the inherent conflicts including different client/worker perceptions of the problem, bias toward the client, and job security concerns of the worker. The author provides four case examples from her own experience highlighting ways to manage these conflicts and identifies systemic agency changes to benefit clients, including increasing the accessibility of medical records and enhancing clinical strategies that ensure confidentiality (p. 299). Social workers are also responsible for alleviating discrimination and identifying prejudicial behaviors among client systems and colleagues and within agencies and communities. Indeed, Hall (2007a) offers an advocacy perspective on gender inequity and argues that the NASW Code of Ethics mandating “ ‘individual well-being’ must be addressed in a ‘social context,’ and attention must be given to ‘environmental forces’ ” (p. 220) means that its male practitioners must take an active position on sexism and “that male social workers have a duty to ensure that females have equal access to all things in a society that males have and that they do so in a variety of contexts” (p. 220). McLaughlin (2009) believes that while advocacy has been largely relegated to the “macro” side of social work, “social workers in direct practice are intimately involved in many aspects of individual client lives including financial, cultural, medical, legal, and spiritual issues, and are therefore able to assess and intervene in many areas in which injustice may occur” (p. 52). She argues for two forms of advocacy— case “to redress power imbalances and promote the rights of individuals who are marginalized or vulnerable” and cause advocacy that addresses “systemic issues and involves lobbying efforts aimed at policy or institutional restructuring” (p. 53). Additional models such as principled negotiation (Lens, 2004) and differential advocacy (Freddolino, Moxley, & Hyduk, 2004)

support active behaviors by social workers to address societal inequities as well as inadequacies within the setting’s service delivery. Hardcastle et al. (2011) explain that “social justice is the sine qua non of social work’s advocacy obligations locally and globally” (p. 341) and identify basic advocacy skills including persuasion, representation, bargaining, and negotiation (pp. 378–383). Empowerment is what social workers seek— whether it is power for individual clients to be in charge of their lives or strong communities that can advocate for themselves. For Hardcastle et al. (2004), empowerment is when a client has increased “capacity to take control over his or her life to improve it” and when a vulnerable group or community has greater participation in decision making for resource allocation and planning for programs (p. 306). Everett, Homstead, and Drisko (2007) believe it may be necessary to identify the goals of empowerment practice at every level of the organization. Their findings suggest that organizations may have greater flexibility than they use in developing programming to recruit and engage disadvantaged families, and that partnerships and collaboration with other organizations can help to reduce costs. These authors advocate greater use of organizational processes that support empowerment practice, such as inservice training. Joslin (2009) poses an empowerment, strengths-based and multilevel framework focusing on custodial grandparents. For addressing individual issues, she suggests changes in attitudes and beliefs, critical thinking skills, and development of a collectivity. To create organizational change toward greater empowerment, Joslin emphasizes increased awareness and participation within the setting itself. Communities, in this model, must gain control over resources to develop shared leadership with providers in multiple roles. Reiter (2009) views art as a tool of empowerment for marginalized people and communities and discusses examples in Brazil where art projects had

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a positive impact on strengthening community development and increasing individual power and control. Some view the term empowerment as controversial in its connection to Western-style and paternalistic development. Jonsson (2010) in southern India argues that social workers must move beyond empowerment theories and models and focus on structural barriers with a view to emancipation instead of a modernization that promotes privatization and consumption. For her and others (Dominelli, 2002; Leung, 2005), the profession should focus on power dynamics at macro levels to understand the social problems and determine their solutions. There are also good arguments to view advocacy and empowerment together. Blyth (2008) believes both empowerment and advocacy are needed to promote gender equality, “to ensure that women and girls are treated equally with men and boys in all areas of life” (p. 223). He urges social workers to serve as a community conscience in advocating, promoting, and addressing reproductive health inequities as a moral imperative on local, national, and international levels. In discussing school violence, Gammonley, Smith-Rotabi, Forte, and GarciaReid (2008) state that school communities share a collective responsibility in ensuring environments that are safe and conducive to learning: empowering students and advocating for educational parity for Hispanic youths is these authors’ call for social justice. Also addressing violence in schools, Dupper and Montgomery Dingus (2008) believe that an empowering act for social workers is to advocate for effective alternatives to corporal punishment and to work to ban this violent act. The concern of Fram, Miller-Cribbs, and Van Horn (2007) for vulnerable children focuses on advocating for mixed-ability peer groups to empower them toward greater school success by exposing them to high-skill peers and the expectations, opportunities, and resources afforded those students seen as having the greatest potential. For these

authors, educating teachers and school administrators on the consequences of ability tracking and building support for integration among the more privileged families whose children are overrepresented in high-skill groups are also important steps toward forging educational equity for vulnerable children. Hardcastle et al. (2004) consider advocacy and empowerment as a joint process, and they caution that empowerment is not always an option: “One could still do advocacy on behalf of involuntary clients. . . . Not every client can be empowered; clients include babies and brain damaged or comatose patients. Nor can every client be empowered by every experience” (p. 375). Social workers practice advocacy to translate private troubles into public matters. As a means to create change in and for individuals and communities, the expected end is empowerment of people to advocate for themselves. The promotion of social justice requires both advocacy and empowerment.

Global Consciousness in Practice Early in the profession’s development, Jane Addams, quoting from Russell, stated, “I imagine centuries in which in the higher minds in the States a noble sense of world duty, a world consciousness, will struggle with mass mentality and gradually pervade it” (Addams, 1930, p. 8). Expanding on international social work, global consciousness embraces a changed world wherein social workers practice with global issues whether in one’s own nation-state or across national borders; it allows for practice through a continuous global perspective, regardless of the initial geographic origin or current location of clients and practitioners. The practice of social work has become ever more demanding now in addressing a world incessantly changing—boundaries are obscured by globalization and technological developments; populations and communities are now simultaneously local, global, and virtual; and the influx of immigrant groups continues to explode into areas not always

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welcoming of them (despite which large numbers may call home), such as Muslims in United Kingdom and France, Mexicans in Arizona, and Asians in Maine. Social work needs theories and practices to ameliorate troubles shared by nations and to attend to emerging problems from large-scale displacements and migrations of people (Cox & Power, 2006) and the devolution of nation-states Polack (2004) concurs that a solely domestic social justice perspective is no longer adequate; social workers must use a global framework to understand a range of issues such as the relationship between increasing immigration and the debt crisis. The term global consciousness has a number of meanings and practices ranging from parapsychology and spirituality, and increasing presence and awareness across worlds. Global consciousness in these chapters focuses specifically on social workers and the demands on them to change their thinking and practice behaviors for the relevance and effectiveness in a global society. Suárez-Orozco and colleagues’ (2007) approach to this term is closest to the one developed and illustrated in this book with its emphasis on learning and understanding in the global era. Repeated from chapter 1, this book develops and uses the following definition of global consciousness for social work: Global consciousness is recognition of the world as a unity consisting of complex interactions among people across the globe. In viewing the world as one ecological system, global consciousness requires critical thinking and communication that is open and sensitive to multiple meanings for the same phenomena.

For the list of items social workers must consider in order to practice with a global consciousness, see chapter 1. It is important to emphasize and make distinct two concepts core to the definition proposed in that chapter: Reflection is part of critical thinking skills and refers to pondering

the professional literature and the range of evidence gathered to consider options for deliberative decision making. Reflexivity is about self-awareness including one’s personal assumptions, values, and social location or “thinking about one’s thinking.” (See chapter 7 for a more detailed discussion.) Advocated by Butcher, Banks, Henderson, and Robertson (2007), the term critical practice captures the essence of a global consciousness as it “entails an open-minded, reflective and thoughtful approach . . . in which careful attention is given to the context in which actions take place and the ways in which different contexts are apt to give rise to different (and often conflicting) assumptions and perspectives” (p. 9). Drawing from peer-reviewed scholarship provides evidence and helps prevent bias. Critical practice with a global consciousness requires using the lens of geographic and cultural context while acknowledging the richness of ethnic diversity and recognizing the client system as the best ethno-specific cultural expert. Charnley’s work in Mozambique points out that “international organizations’ continuous engagement with different knowledges and different ways of knowing” must inform interventions that can support the capacities of a community and its children (Charnley, 2007, p. 266). Use of person in environment must now include geographic variables in addition to those of ethnicity, race, and culture. Hancock’s (2005) overview of services to rural Mexican families in the United States indicates the importance of attention to the community and its social supports along with the migratory experience itself and the level of employment skills. Leigh (2009) reports on a thoughtful hybrid approach in Merced, California (120 miles south and east of San Francisco), where a hospital shaman program strengthened the trust of the California doctors by the Hmong community. Keough and Samuels (2004) illustrate a global consciousness, as well as use of a biopsychosocial approach and collaboration

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between social workers and other mental health and public health workers, to support families after the conflict among Serbians and Albanians in Kosovo. A public health and social work team from Boston-based Physicians for Human Rights (PHR) planned and implemented a community-based intervention that mobilized local mental health providers and established collaboration among national and international agencies, including the International War Crimes Tribunal for the Former Yugoslavia (IWCTFY), to provide a support network for families with missing family members. PHR public health and social work professionals trained local staff and social workers as interviewers to collect antemortem data from families to aid in the identification process. Increasingly, U.S. schools of social work are developing ties with international programs and study-abroad field placements. Rotabi, Gammonley, and Gamble (2006) argue that social work faculty “carefully link the aims and methods of study abroad with some of the broader purposes of international education to develop an awareness of self outside one’s own culture, to promote intercultural communication, and to encourage flexibility in adapting to a rapidly changing world” (p. 453). They propose the following principles: social justice and human rights, community capacity, dignity and worth of the person, self-determination, boundaries, competence, facilitative learning, and integrity (p. 454). Cwikel, Savaya, Munford, and Desai (2010) encourage collaboration and discourse among social work programs to consider innovative approaches to educate for global practice. It is important to keep in mind that practitioners need a global consciousness within and across borders. The thrust here is not a change in the physical locale of the social worker but a change in that worker’s ideas and perceptions. Wikberg and Bondas (2010) offer a clear example of such practice in their discussion of intercultural caring as an overarching metaphor for practice with a global consciousness

that takes into account the uniqueness of each person and situation while also recognizing the universality of some experiences; in this research, the focus is on maternity care. Intercultural caring incorporates some of the dimensions of a global consciousness including attention to uniqueness, context, culture, and universality along with an “inner core of caring consisting of respect, presence, and listening” (p. 1). Also necessary to consider are external factors such as economic and organizational issues as well as a person’s legal status, issues of power/control, and racism. The following cases illustrate global consciousness in practice. Further cases highlighting global consciousness for social workers follow later in all remaining chapters.

CASE NARRATIVE: SUZANNE—CULTURAL SENSITIVITY AND EMPOWERMENT FOR GLOBAL CONSCIOUSNESS

Suzanne, who has been practicing social work for more than 20 years and for the past 7 years as director of social work, discusses several examples of practice with a global consciousness. For many of the social workers within this large urban hospital in a major U.S. city, at least two thirds of their caseloads consist of individuals who have arrived in this country in recent years (native areas include Mexico, the Mideast, Asia, Brazil, Dominican Republic, Ecuador, Colombia, Senegal, Kenya, and Haiti). This is a huge department with about 200 master’s-level social workers dispersed throughout the hospital from outpatient child psychiatry to inpatient adult surgery. More than 47 languages are spoken by the very diverse mix of clients; translators are available, in some cases via phone. We are all clinical social workers and by that I specifically do not mean we are psychotherapists, but are advocates, case managers, family therapists, group workers; out of curiosity and true interest in our clients, we get out into neighborhoods to see where our clients live. Our population is

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continually shifting as new immigrant populations move to this city; this means we can take nothing for granted. We try to maintain diversity within our staff and still are constantly challenged by the diversity and differences within and between the patients’ ethnic backgrounds. A good example of this is a case we had the other day. An African woman in her thirties was admitted to the OB-GYN unit for emergency delivery of her baby. The infant died at delivery. We assumed she was Muslim and would therefore want the placenta in order to bury it, so placed it aside for her. She started a continuous chanting and wouldn’t respond to any of our efforts to communicate. After many hours, some staff became concerned that she was decompensating and wanted to get a psychiatric consult. One of our social workers entered the room and recognized the chanting as Jewish prayers (she was herself Jewish). The social worker learned that the woman was an Ethiopian Jew and that her closest relative was a brother who lived in France. We were then able to contact him and assist the client in arranging for a prompt burial, as mandated by her religion. We spend a lot of time in staff meetings talking about the impact of culture on health care delivery. I sit on the hospital’s diversity committee where we consider ways to serve the many cultural groups who populate this city as well as those newly arriving. To better relate to the increased East Asian population, we have increased our Asian staff, and to be able to communicate with the French African populations, we have hired more French translators. Yet, we know we can’t be expert about all cultures and ethnicities and anyway, we have found so many differences within groups. We worked with a female patient from Mexico with high glucose levels. Before placing her on medications for diabetes (she was borderline), we wanted her to try changes in her diet. Despite meeting several times with a nutritionist and agreeing to the changes they discussed, her levels continued to rise. We brought the family in for a meeting and learned the husband had been demanding his favorite dishes of fried rice and fried plantains

(income did not allow for different meals for each family member). We had some very direct conversations about potential effects on the family should the mother need injections or become ill with diabetes, and the father agreed to support, and himself follow, the recommended diet. We always supplement the evidence we rely on with the latest peer-reviewed literature. This helps ensure we remain current with the latest findings and facilitates accurate assessments, strategic interventions, and evidence-based practice (EBP). In this case, a recent study by Metzger et al. (2009) supported our hypotheses that not only is the fetus at risk when the mother has high blood sugar, but so is the mother during this pregnancy and in future pregnancies and she could possibly remain at risk for the rest of her life. Changes in diet and exercise were critically needed. Now we see many Mexican families, not all of who have problems with diabetes or with obesity. In this, as in all our cases, we are prepared to communicate cross-culturally, but the most important is the meaning our clients ascribe to particular events and our continuing respect for human rights. In supervision and team meetings, we discuss our own biases and reactions (food and weight seem universal themes), so that we can remain attentive to issues relevant to this client at this point in time. Note the importance Suzanne places on awareness of self outside one’s own culture, attention to biases and assumptions, and respect for cultural difference and for the uniqueness of each person. She works with her staff to promote intercultural communication and to seek the meaning clients attribute to the events in their lives, recognizing they may or may not be culture-bound. In drawing from peer-reviewed literature, they use evidence for practice (increasing their overall EBP and critical thinking skills).

The remaining case studies in this chapter illustrate practice with a global consciousness using ethical reasoning and advocacy for empowerment.

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CASE STUDY: JENNIFER—SOCIAL JUSTICE AND ETHICAL REASONING FOR GLOBAL CONSCIOUSNESS

Practically everyone in my family has gone into law enforcement. I was a cop for 10 years when I decided to get a social work degree. Now in my early thirties, I’ve been with a legal aid office for 3 years. When I learned about professional dissonance, I realized it applied to me I was increasingly uncomfortable as a police officer even though I then and now have great respect for the good police do for individuals and communities. My work as a cop allowed for little of my own ethical decision making, pressure was on us to reduce violence and get ‘bad’ people off the streets, yet justice was not always served. After getting my MSW I joined this legal aid office and kept seeing our clients arrested and brought into the criminal justice system from which they seemed unable to escape. One such adolescent, Jenson, age 16, had no arrest record, although was a member of one of the local gangs responsible for a spate of shootings and got caught with a small amount of crack/cocaine. He had been in juvenile detention for almost two months until we had contact with him. He and his parents recently moved to this large urban area from Brazil. I was struck by the contrast between strict laws that unfairly singled out these young men. As a police officer, I had not really considered these matters, yet my decision to become a social worker was in many ways initiated by my discomfort with the criminal justice system and concern for the well-being of these adolescents. Practice with global consciousness toward social justice and human well-being is complex. In addition to Jennifer’s knowledge about policies that impede rather than increase fairness, she also needed knowledge of the literature and ethical codes to help change these policies and skills to advocate and empower her clients. This would include data about the criminal treatment of adolescents and the conditions in detention centers. Glaring disparities, for example, occur in New York State with more than half of the

adolescents sent to detention centers for misdemeanors such as theft, drug possession, and truancy. Blacks and Latinos composed more than 80% of this population despite making up less than half the state’s total youth population. Many of these youth were found to have addictions or psychological illnesses for which less restrictive treatment programs were not available. Three quarters of children entering the juvenile justice system have drug or alcohol problems, more than half have had a diagnosis of mental health problems, and one third have developmental disabilities. Moreover, even those youth not considered dangerous have their hands and feet shackled while being transferred from their homes to the centers, and “sometimes even belly chains” were used (Confessore, 2009). A second issue is runaways. Of the 1.6 million children in the United States who run away from home each year (either kicked out or fleeing abusive or other unpleasant situations), many return home within a week. Those who don’t often engage in prostitution or pimping, indeed nearly a third of these runaways engage in sex for food, drugs, or a place to stay. Such bartering often escalates, making it even more difficult for child welfare workers and police to help the runaways get off the streets thereby further trapping them as teenage criminals instead of treating them as tragic and young victims. State cuts to youth services and a lack of residential programs have escalated these problems (Urbina, 2009). A third issue is the high U.S. incarceration rates, especially among males of color. As Blow (2009) reports, the United States has more inmates per capita than any of the 36 European countries with the largest inmate populations; indeed, the U.S. total is more than all the inmates in those countries combined. Figures for 2008 showed a decline for the first time in four decades; overall, there were 1.6 million prisoners in state and federal prisons at the end of 2008 with an increase in the incarceration of white males. Nevertheless, blacks still continued to compose the largest segment, 44% of all prisoners serving time for drug offenses, even though they were only 12% of the total population. Whites (75% of the national population) represented 27% of all imprisoned drug offenders. The incarceration rate for Latino drug offenders in state prisons was 20.2%

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(Moore, 2009). Unfair sentencing policies also disproportionately affected black women who now show a striking decline in incarceration, a 30% drop from 2000 to 2009. Drops in crack-cocaine use and changes in the sentencing laws have resulted in rate changes for men; with black males now comprising 38% of the prison population and white males at 34% (Goode, 2013). Jennifer also needed a broader perspective on the approach to and meaning of incarceration in other nations. A New York Times editorial column was most informative. In it, Jennifer learned that Germany’s use of incarceration was “to enable prisoners to lead a life of social responsibility free of crime upon release” while the Netherlands had short sentencing with focus on community service programs (Editorial Board 2013, p. A34). Jennifer was puzzled by the contradictory nature of the United States as being at the same time a nation of immigrants yet imprisoning so many of them. It was important for Jennifer to be familiar with these debates from the professional literature and perspectives in different nations in order to engage in critical thinking and ethical decision making. Policies, concepts, and ethical challenges cross borders with some arguing that the profession has abandoned youth delinquency as a social issue despite social workers’ practice with this population. Bradt and Bouverne-De Bie (2009) criticize the shift to restorative justice, which they see as punitive; they would rather emphasize rehabilitation and prevention, requiring social workers to engage the individual juveniles in trouble and their families along with community and policy issues. After educating herself, she attended to this broad and complex context of person and environment to advocate for changes in drug laws, publicly highlight the incarceration disparities, and empower her clients raised in problematic conditions such as discrimination, limited options for youth in poverty, and gangs. She made sure to remain informed about the various approaches to ameliorate these social problems. Yaccino’s (2014) report on reducing gang violence in Chicago supported greater use of social services, in tandem with police, to prevent gang retaliation, which was identified as a primary factor in Chicago’s high homicide rate. Seabrook’s (2009) report

on efforts in Cincinnati that were not as successful still indicated the importance of social services in reducing violence and improving community safety. Such data empowered Jennifer to advocate in her setting for building relationships among lawyers, social service settings and the police. She also kept careful records and notes her decision-making process and, although she often felt stressed by the complexities of the cases, she also appreciated the greater options she now had to promote well-being for the adolescents and the community. Her openness to a global society enabled her to acknowledge her own distinct ideas yet feel in community with many “others” including the police, members of gangs, families from other nations and of course social workers. In her ethical reasoning she knew that protection of bodily harm superseded another’s selfdetermination, but the crux of the issue in her practice is the lack of protection for all these persons so harshly sentenced and treated as well as for the community at large. She knew policies and practices needed to change.

CASE STUDY: ELLEN AND CARMEN— ADVOCACY AND EMPOWERMENT FOR GLOBAL CONSCIOUSNESS

To consider mental health service delivery from a global perspective, we return to Ellen and Carmen from earlier in this chapter, who had different approaches in practicing with potential suicide risks. Policy shifts and expanding treatment options within the United States and the differences between nation-states offer complex challenges for social workers in this field. Collaborating with the staff psychiatrist and unit psychologist, Ellen advocated for better resource allocation to outpatient services. Arguing for frequent and regular meetings with discharged patients and their families, she eventually developed a model outpatient program that resulted in fewer readmissions. A strong outpatient unit enabled staff to move ahead more confidently with discharge planning, hospital stays became shorter, and for

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some clients (Jane included) the return to living in the community allowed for empowerment and self-determination. Populations that could benefit from expanded community-based care are growing, including, in addition to mental health, transitional housing for people released from prisons, nursing care for elderly people instead of large nursing homes, and small residential housing for adolescents in trouble. Such changes require advocacy by social workers who are informed about the population’s needs and evidence about the problems and strengths of such projects both globally and domestically. For example, Kolko, Cohen, Mannarino, Baumann, and Knudsen (2008) discuss models for community treatment of child sexual abuse, and Koss, Bachar, Hopkins, and Carlson (2004) consider public health collaboration in addressing sex crimes. Hartocollis (2009) presents the abuse and neglect for some with mental illness who are still placed in large institutional settings where they are socially isolated and disempowered. Even though they are technically free, they are in many ways imprisoned. While some supervision is necessary for safety, small community-based housing can provide safety and dignity. The lack of these settings also results in the actual imprisonment of people with mental illness (Bernstein [2009], who reports on the use of detention instead of care). There are also political agendas in treating individuals as mentally ill. Jacobs (2008) reports about the city of Xintai in Shandong Province institutionalizing residents who exposed corruption or complained about what they considered an unfair seizure of their property. Some commitments were 2 years, with forcible medication. After Carmen’s serious car accident resulting in her need for a trained dog, she made some major life decisions to work with people suffering from mental disabilities. Designated as one of the country’s screening centers, the hospital-based Psychiatric Emergency Program where Carmen was employed had some walk-in clients, but the majority of them were referred by police, jails, schools, families, and the hospital’s emergency room. Policies and the profession’s ethics privilege an individual’s right to selfdetermination making it difficult to commit persons for mental health treatment against their wishes.

Ellen and Carmen also attended to their own personal worldviews to ensure a good fit with the profession’s values. They especially resonated to Taylor’s (2009) reports on use of painting and other art forms to enhance communication for people with mental illnesses. The reduction in social isolation and increased overall social functioning fit with their own strengths-based approach to use advocacy and empower their clients. The U.S. government finally instituting mental health parity (equal coverage for the mental disorders) as a civil rights issue (Pear, 2008) was a critical achievement in Ellen’s ongoing practice with clients needing these services. Contemporary practice demands that Ellen and Carmen develop broad perspectives that reflect recent advances in knowledge and technology as well as global issues in mental health care. Linkages between diagnosis and insurance coverage for services is especially strong in the United States, with interference by drug companies who reap huge financial benefits often making it difficult to get at the objective evidence for best practices. Here again, social work leadership is needed. Work by Gunnmo and Fatouris Bergman (2011) provides an international perspective on increasing well-being for people with schizophrenia, and Herrestad and Biong (2010) present international perspectives on practice with patients who inflict self-harm. Disparities in the geography of mental health occur within nations and across borders. Where people live and their financial situations affect their access to good health care in general, the kinds of health problems they have and the meaning of these problems to the larger society. Hudson (2012) commends efforts by social workers to reduce these disparities and encourages greater focus on community needs assessments to particularize the extent of services needed and where. The approach to health insurance in the United States, where those with good jobs receive employercovered health insurance benefits, still leaves millions of Americans without such coverage, some of whom end up in the prison population. Encouraging shifts are reported by Goode (2014) that prisons and jails are signing up inmates for President Obama’s Affordable Care Act. Such coverage will be especially helpful even after they leave prison; persons in this

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population often have high rates of chronic diseases with few opportunities for employment.

Challenges Many challenges confront the social work profession for ethical practice in a global society. Demands for a greater scientific knowledge base and applied skills for insurance reimbursements have dominated over the needs for attention to social work’s base in values and the social welfare during a period when changing technologies and vast movements of people have transformed human interactions requiring ever more ethical guidance for decision making relevant across and within nation-states. Social work values need to be clearly defined and protected as they provide the one constant able to unite the profession internationally and across specialist areas of practice. As stated by Larrison and Korr (2013), “When we unite based on our core values and common base, issues of epistemology, ontology, and methodology no longer become dichotomized forces tearing us apart” (p. 205). Wakefield (2005b) argues that it is critical for the profession to resolve what has become a division between its clinical practice assumptions and its social justice mission. His translation for social workers of Rawls’s complex system to attain fairness emphasizes relationships between psychological problems and lack of social justice and explains the concept of the social minimum (or minimal distributive justice) in framing “social work, then, as a ‘safety net’ . . . interpreted broadly to encompass protection against unjust deprivation” (p. 294). Lundy and van Wormer (2007) comment that “the discrepancy between social work practice and social work values is greater in the USA than in Canada” (p. 728). They believe that the basic contradiction between social work values and the current economic realities point to the need for social workers to unite globally and that a human rights perspective can strengthen the social and economic justice arguments.

Reisch and Andrews (2002, p. 231) encourage a “willingness to struggle on, . . . , to translate these values into deeds, as our professional forbears did individually and collectively” (see also Reisch, 2013). Tsui, Yan, and Chung (2010) raise concerns about social workers’ capacity in the Asia Pacific region to confront the difficult challenges of power differentials and privilege inherent in indigenization and globalization, and they argue that regardless of where the social work is being practiced, social workers remain focused on social justice as the most valued tenet of the profession. Yet the range and severity of problems that indicate lack of social justice continue to grow. Glaring ones include: t
Poverty with its far-ranging ill effects on health and human well-being. IFSW reports that 80% of people across the globe live without access to adequate social and financial resources (2014). Klass (2013) emphasizes problems resulting from poverty in child development, further reducing social mobility. Hacker (2012) estimates from the 2010 U.S. Census figures “the lower 60 percent of households have lost $4 trillion most of which has ascended to the top 5 percent” exemplifying the increasing disparity between rich and poor within the United States; disparity is also growing between rich and poor nations. t
Pollution, assaults on biodiversity, and toxicity in agriculture have a disproportionate impact on the poor (Bullard, 2005), with recent research indicating that the effects of pollution on pregnaunt women can result in low birth weight leading to later health problems (Bakalar, 2013). t
Extraordinary needs exist for access to health care, jobs, education, safety, housing, healthy food, and clean water, among many others. Leadership by the profession is ever more important in a world where international developments increasingly

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dictate the availability of social and economic resources as well as access to them by social work clients and at the same time present a shared set of problems such as HIV-AIDS, violence, substance abuse, unemployment, poverty, and starvation, among others. t
Increasing exclusionary policies beginning in parts of Europe and the United States against immigrant populations during this period of increasing mobility across national borders. t
Social work is already an international profession, with organizations in many countries and a large membership in the International Federation of Social Workers, yet this does not necessarily translate into knowledge and skills that meet global challenges. Education of social workers could integrate social justice into the research curricula (Vincent, 2012) and broadly into curriculum as a whole (Birkenmaier et al., 2011) and could apply justice theories to policy advocacy (Granruth, 2009). Future Directions Hong and Hodge (2009) pose a fourdimensional conceptualization of social justice in attempting to provide greater definitional clarity including forefront professional values to enhance roles for promoting these aims; building a micro to global process to challenge social and political systems, individual capacities, and family environments; and constructing outcomes to indicate progress in economic and social justice, human rights, social welfare, and diversity (p. 216). Lacroix (2006) links social justice and oppression with the international and local as a “crucial and necessary perspective in order to promote the rights and opportunities” of asylum seekers, arguing forcefully for the enforcement of non-refoulement—the right of not being forcibly returned. Detention of those fleeing persecution may not take into account their challenges in having sufficient

documentation, creating problems in access to work (even for highly educated professionals) and increasing family separation problems (p. 25). Also addressing inclusion/exclusion, Cemlyn (2008a) targets the well-being of Gypsy and Traveller populations within Great Britain and the particular challenges they face due to social exclusion. She argues for an advocacy and human rights approach in dealing with these communities and with minority populations in general. Frequently, Gypsies and Travellers are nomadic and experience prejudice, denial of basic rights, and inability to access services such as medical care or education. “A paradigm shift is needed away from sedentarist frameworks so that Gypsy Travellers’ experience is heard and understood in its structural context, and their needs/rights inform practice. . . . At the prevailing macro level of practice, a rights perspective could assist social workers in challenging the boundaries of oppressive criteria and assumptions” (pp. 165–166). From a micro-practice perspective, she encourages social workers to incorporate the “cultural perspectives and daily experiences” when completing needs assessments or referrals for other services (p. 166). A central thrust of the human rights paradigm is that “needs should be participatively defined, and that rights are implemented through meeting needs” (p. 165). Several authors consider issues of restorative justice including social work’s role in the resolution of conflict and recovery from violence (Androff, 2008a; Sacco & Hoffmann, 2004). Gumz and Grant (2009) believe the profession must return to its roots “in building models of community rehabilitation and justice” (p. 125); they offer to communities, victims, and offenders an alternative to incarceration to address “the harm caused by the crime” but not create more harm (p. 119). Practices to substitute include mediation, or direct interaction between victim and offender; family group conferencing, a model developed in Australia that would include secondary victims such

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as extended family and the offender’s family; and peace-making circles from aboriginal and Navajo traditions inclusive of the above and community members and friends meeting in circles. Wronka (2007) advocates for global distributive justice in his calls for reducing disparities between rich and poor nations. Based on their definition of social justice as a “demonstrated investment in fighting multiple forms of oppression, including racism, homophobia, ableism, sexism, agism, classism,” Wiener and Rosenwald (2008, p. 126) believe symbolic interactionism is a theoretical model that could help incorporate social justice into social work curriculum. These authors “interpret social justice as a vital expression of human interaction that is deliberate and not merely natural because, according to the theory of symbolic interactionism, human actors behave interactively to create our experiences” (p. 126). Tschakert and Machado (2012) examine the need for empathy and empowerment to address ecosystem sustainability, and Dominelli (2012) encourages social workers to raise awareness of greenhouse gases for mobilizing communities to advocate for equitable carbon-sharing schemes and dialogue with policy makers. Powell and Geoghegan (2005) argue that “for postmodern social work, the challenge is to break out of the mould of clientisation and discover a more inclusive practice based upon civic engagement, in which clients are reconstituted as citizens—civic social work” (p. 130). In distinguishing citizenship, as opposed to clientization, they offer the following principles to guide civic practice: social inclusion as the profession’s stated aim; redefinition of risk away from its current focus on danger into a vocabulary balancing rights and risks; trust as symbolic practice; relationships seen as dialogical; justice and social obligation; participation and empowerment; multiculturalism; poverty addressed with employment policies; and prevention of social exclusion (pp. 142–143).

Other perspectives to address differences include Clifford and Burke’s (2009) antioppressive ethics to prioritize focus on unequal social and political contexts. Hugman (2005) suggests an ecological orientation to take into account systems, social relationships, as well as a wide range of interactions including those that are ecosystemic. Healy (2001) raises concerns about globalization’s homogenization of policies that could reduce rather than enhance social welfare systems. She too would like to see “social work as a force for humane global change and development” (p. 260). Multidisciplinary perspectives will be necessary to achieve a more caring and just society and will require social work to collaborate with a range of disciplines for development of knowledge usable by its practitioners (a good example of such collaborative work is Koggel & Orme, 2010) . Some contemporary philosophers (Appiah, 2003, 2010; Doris, 2002; Hursthouse, 2002; ) now draw from Aristotelian virtue ethics as have feminist philosophers (Brennan, 2003; Koggel, 2002; Sherwin, 2002) in their analyses about the impact of relationships on equality and oppression, and it is attracting increasing attention from among social scientists and the social professions (Banks, 2004; Bisman, 2008b; Dworkin, 2000; Hugman, 2005). Most importantly, social workers must find their voice to contribute their profession’s perspectives on the truly difficult and mounting challenges of the 21st century that affect human well-being. Working within social work organizations along with joining already established groups, the social worker can reach a wider public audience. Below is a partial list of the many areas needing attention: t
Address poverty and its many ramifications. Speak out on continuing debates about the minimum wage—as of April 2014 (Shear) state governments are acting more forcefully than the federal government with vastly different amounts, ranging from Washington ($9.32 an hour) to

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Wyoming ($5.15); there are five southern states with no minimum wage laws. Reisch and Jacobs (2014) point out the growing inequality with the wealthy receiving services for which they pay very little. Consider normative positions to augment your arguments (Gauri & Sonderholm, 2012). t
Educate the public that voting rights are civil rights (Ackerman, 2014) by invoking some of the 1960s activism to once again enable oppressed persons to vote. t
Participate in actions to improve global health to reduce infant and maternal mortality rates, increase access to medications, improve sanitary conditions. t
Incorporate climate risks into assessments, citing the deleterious effects of pollution. Jacobs and Johnson (2014) report that pollution has killed 7 million people across the globe in 2012. t
Advocate for mental health care and services including training of police and prison personnel. t
Work to reduce incarceration rates and the substitution of jails for mental health services. Prisons continue to be crowded with increasing violence and are becoming a trap for poverty (Tierney, 2013). t
Advocate for oppressed groups including women who continue to face rape, violence and reductions of rights in many nations across the globe. t
Speak out on the needs of refugee populations and argue for humane immigration policies. Powerful political divides in the United States prevent simple changes such as providing a path for “permanent residency” (not even citizenship) for undocumented persons who arrived with their families before the age of 15 (Weisman & Parker, 2014) while seeking high deportation rates. Building on social work’s history, values/ ethics, and intellectual struggles, these contributions may not only aid contemporary social

workers in reconciling the profession’s roots of charity organization with settlement but also help solidify understanding of its moral function. Summary Social work’s historical base in morality within the context of its status as a professional occupation was explored as we considered how values and ethics emerge from a profession’s mission of service to society, distinguishing and regulating the profession as well as informing and guiding its knowledge and skills. This chapter focused on the aspirational ideals of social work, emphasizing that without this moral base, there is no social work function in society. Acknowledging this heavy service orientation to promote social justice and enhance human well-being, we considered a range of ethical codes and standards and examined the direct linkages between social work’s mission and the values of service, human dignity and relationships, and integrity and competence, as well as the inherent contradictions within and between the ethical standards while seeking to clarify the ambiguity of social work’s highly abstract mission to better inform practice. Case studies illustrated practice guided by ethical standards and reasoning and a global consciousness. This new construct for the profession was defined as recognition of the world as a unity consisting of complex interactions among people across the globe. In viewing the world as one ecological system, global consciousness requires critical thinking and communication open and sensitive to multiple meanings for the same phenomena. It also extends international social work and cultural competence for practice in a very changed world wherein social workers practice with global issues whether in one’s own nation-state or across national borders. In its respect for the uniqueness and dignity of each person, global consciousness addresses issues of diversity and difference with sensitivity to a range of border crossings writ large to include issues of class,

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race, ethnicity, and nation-states. This construct recognizes the social world as one ecological system with multiple subsystems that are in continuous interaction. The movement of peoples requires a change in social workers’ ideas and perceptions, not a change in the physical locale of the social worker. The world comes to each location. Social workers need the lens of geographic and cultural context to understand the impact of place and background on behavior in order to promote civil society and advocate for human well-being and the empowerment of people. Also considered were ethical perspectives drawing from philosophy, law, and a range of social scientists and social work scholars to consider cultural relativism, human rights, and ethical reasoning to enrich the profession’s discourse about our purpose and to enhance our ethical practice toward social work’s mission. Appiah (2005) makes a critical distinction between living well (ethical) and treating others well (moral): “What is it for a life to go well?” “What do we owe to other people?” His thoughts about rooted cosmopolitanism challenge us to consider what it means to be “citizens of the world”—a cosmopolitan—which for social workers has become a necessary goal for practice to meet social work’s mission to promote social justice and human well-being. Essentially, to make the world a better place. We face a challenge to dialogue together and articulate contemporary approaches to enhance human well-being. This chapter calls on all of us in social work to accept our contemporary calling to attend to the social welfare both globally and locally with attention to individuals and to the social environment: the macro and micro are both real and essential in attention to the social morality. This chapter has argued that ethics is the language to facilitate the necessary shared set of values for belonging and caring in a global world. Der Derian (2009) suggests “Ethics is as much the product of how as it is the object of

what we study” and “tightens the bond between theory and practice” (p. 295). The knowledge for social work practice covers complex client systems that are continually changing as they interact with each other and the world at large. Integrating concepts and principles with ethics and values creates challenges and suggests future directions for building on what makes social work unique—its overall mission to enhance human well-being and alleviate oppression locally and globally. Exercises Application of social work’s ethics and values A. Consider the following questions as you read the case below. 1. Identify and discuss at least three values and three ethical principles. 2. Outline at least two approaches to ethical reasoning that might be applicable. 3. Explore the issues of advocacy and empowerment evident in the case; list at least two of each. 4. Explain how your approach will promote social justice within a global context and identify at least three relevant points. 5. Comment on the global consciousness necessary for your practice with this case; list at least three relevant points.

EXERCISE CASE STUDY

You are employed in a publicly funded family services setting. About 70% of the families that you work with are from a minority ethnic group, Sikhs. The 16-year-old son has had learning difficulties, long periods of depression, and is monosyllabic. All of the contact has been with the mother, and the father’s attitude is “Oh you need to speak to my wife, that’s not my concern, she deals with the young man and she’s to do with that.” For them, these are traditional roles for the father and the mother. The father had really in some ways rejected this son.

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The mother is in her early thirties and has been married since she was 16 or 17. In contacts with her about the son, you learn that the husband is abusive to her, there was no physical violence toward the children, although there was an effect on the children because they were aware of what was happening. The violence started at the same time his business began losing money; he would then start to drink, and that’s when he would be both verbally and physically violent to her. The father was struggling to earn enough money, he would leave at 5 or 6 o’clock in the morning and then maybe not return until late at night and also work on weekends. For many of the women in this community, it’s like they are single parents. It is also common for these families for parents to share a bed with the small children and for children to share small rooms together. The son tended to spend time at a local park, which is near the family home. Recently, teenage girls came up and started calling him racist names and names about his disability and his appearance, something like Paki (which he is not), mongrel, or weirdo. The father felt their reputation was sullied and humiliated. The son was locked up overnight, and he alleges that he was kicked and water was thrown over him.

B. Explain the function of values and ethics in professional practice. Draw on at least two examples from your practicum to illustrate practice consistent with the ethical principles of informed consent and confidentiality. Identify two other cases illustrating a conflict between duty to protect and self-determination. Advocacy Project: Communities, Policies, and Organizations Advocacy “has a role in transforming private troubles into public issues or personal problems into social issues. It has a responsibility in challenging inhumane conditions at a micro or macro level” to promote social justice (Hardcastle, Powers, & Wenocur, 2011, p. 340). 1. Prepare a testimony to deliver in front of a public group (e.g., city council, school board, legislative or lobbying group, county health board). 2. Drawing from this exercise, identify what you learned about advocacy. 3. List 3 things to do to integrate advocacy into your social work practice with communities, policies, and organizations.

4 Evidence for Knowledge-Guided Assessments Diagnosis begins as soon as one encounters a particular situation, and never ends. . . . The way one sees through a situation changes the situation. As soon as we convey in any way . . . what we see or think we see, some change is occurring even in the most rigid situation. —R. D. Laing, psychiatrist It is not the details, as such, that matter but the relationships among them. —Margaret Mead, anthropologist For practitioners, if assessment is not directly related to and prescriptive of treatment, it is, at best, a waste of client and practitioner time and, at worst, unethical. —M. A. Mattaini and S. A. Kirk, social work scholars and teachers We write up risk assessments and risk management plans, but that’s not the end of it. People’s circumstances change so the assessment has to as well. It’s learning about where people are at any one point in time and being flexible and open enough to follow what they are saying. —A social worker

M

aking sense of the world around us is something humans do on a continual basis. Bombarded with phenomena, we decide what to focus on, rationalize why these things in particular warrant our attention, and prioritize the timing in dealing with them. The “what,” “why,” and “when” of these

decisions occur quickly, often outside our awareness. Yet, social workers must transform what they do naturally into a thoughtful professional activity. This is especially so for assessments: if they are not valid or relevant to the client situation, even the best intervention will not relate to the client’s needs, potentially causing great harm. Social workers have a moral responsibility to formulate assessments with a high level of global and critical consciousness in order to draw from evidence that will facilitate understanding of each particular client situation among a wide range of complex and changing variables. Our definition of global consciousness introduced in chapter 1 includes critical thinking, skills of reflection, and the lens of geographic and cultural context integrated with peer-reviewed scholarship. Moreover, the actual understanding of each case—the case theory—must embody belief in change and reflect current knowledge and best practices. To practice ethically in a global world, social workers must draw from a broad range of evidence including current literature, keep an open and inquiring mind, and have tolerance for differences and for ambiguity. Whether clients are individuals in distress, families in turmoil, communities with high crime, or agencies in chaos, social workers have to sort out a range of data that are at times contradictory. For example, a 16-year-old female involuntarily committed by her mother to inpatient psychiatric care for a suicide attempt (serious overdose of pills and four previous records of visits in the past 2 months to the 93

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hospital’s emergency room for similar behavior) insists “it was just an accident” and that she does not want to return home with her mother because of the mother’s boyfriend and problems at school. The mother moved from Iran to the United States with her daughter, then 13 years old, to join her husband; after a year, he disappeared (possibly moving back to Iran). Her only resource for financial and other help was the husband’s family, who blamed her for the husband’s disappearance. The relationship with the boyfriend, also Jewish, but not Persian, began a year ago, coinciding with the daughter’s school problems. Reflecting our previous discussions about social work’s biopsychosocial perspective, its multiple levels of practice, and a global consciousness, the social worker’s assessment must consider this client within her circumstances and therefore cover physiologic factors, psychological issues and diagnoses, and the social environment. Each of these areas contributes critical perspectives for understanding the current situation and sorting out contradictions between her statement now of an accidental overdose and the four other such events in a 2-month period; additionally, they allow for consideration of safety in the home, school, and broader community. How do social workers decide on the amount of evidence to gather? What to do with conflicting information? How to use this information? Which sources provide the best evidence? We address these questions in our exploration of assessment as the conceptual core of social work practice. The focus is on developing critical thinking skills needed by social workers to manage the basic details of problem situations within context of the larger picture. Moreover, as Laing’s quote reminds us, perspectives by observers affect what is being studied, necessitating the use by social workers of a wide range of data from multiple sources to contain bias and personal experiences from limiting the assessment, as well as to consider various explanations for what is happening. Similar to the evidence needed for effective interventions,

discussed in chapter 8, valid assessments require continual gathering of evidence from individuals, family members, community representatives, and conceptual frameworks. The data from the sources are not static and neither are the ideas and assumptions inherent in them. This is especially so with conceptual frameworks from the professional literature. Concepts are constructions to understand the world, but they are not reality: as ideas to explain changing phenomena, they themselves must change. A critical source of evidence, therefore, is from research, concepts, theories, and approaches discussed in the professional literature. Peerreviewed journals, books from a reputable press, and a range of statistical material (census figures, United Nations reports, etc.) are all accessible and should be used. Scholarship on populations and problems pertinent to situations faced by clients adds critical information needed to ground assessments in knowledge respected by experts in the field. While each client situation is itself unique, it is rare to find general issues that no one else has encountered. In today’s networked world, there is no excuse to practice without benefit of knowledge from peer-reviewed literature (articles and books from publications respected in the field). Despite the importance of all the practice components and their complex interconnectivity, assessment is the most critical of the practice components. It informs the relationship boundaries and purpose, communication interactions, differential use of self, and ultimately directs the intervention. Hardcastle et al. (2011) concur: “Assessment is necessary before intervention, unless intervention is done by rote or at random. . . . Community assessment is a necessary aspect of any case assessment to understand both the content and context of the case.” Similarly with organizations, assessments are necessary to understand the auspices (who is paying for what), the agency mission and purpose, the formal and informal structure, overt and covert authority, and power sources.

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Such information makes it possible to create change at all levels of practice (p. 134). At the same time, it is not possible to gather data about the client and the problem without relationship bonding or direct communication with the client; interventions will be haphazard without a clear statement of “what” is happening that then leads to “how” to change the problem situation. Information about best practices and differential use of self are necessary for assessments that are not based on practitioners’ personal feelings, preferences and values but rather guided by the profession’s knowledge and code of ethics and by what clients mean, want, and need. In this chapter, we examine assessment as a mutual process engaging client and worker in gathering and organizing evidence that advances from the particular to the universal to the singular. Constructed from this evidence, a case theory provides a theoretical linking of a client’s past with the present and future and organizes a biopsychosocial approach to practice for this single client at this point in time. We explore how evidence includes facts, observations, and multiple outside sources from the professional literature (peer-reviewed or reputable publications) that are conceptual, quantitative, and/or qualitative. In the range of case studies presented, social workers explain how they construct the assessment; the focus is on the process—“making sense” of what they do to gain understanding of the client. The chapter concludes with assessment approaches for families, organizations and communities, and an example of a biopsychosocial assessment for individuals. Frames of Reference on Social Work Assessment In the early years of U.S. social work, Richmond’s view of assessment included both what the social worker does (the process) and what the social worker produces (the report). Writing almost 60 years later, Siporin (1975) concurs that “Assessment is both a process and a product of understanding” (p. 219). This dual

meaning applies across the multiple levels of practice discussed in earlier chapters. Writing about one’s understanding of a problem situation provides a record usable by clients and other colleagues whether of a community, organization, or individual. Recognition and explanation of problems establishes the need for change. Hardcastle et al. (2011) point out that these various client populations each pinpoint particular problematic areas requiring change efforts. Those addressing community may “devote more attention to the social ecology, the environment, and the social systems” (p. 12). Organizational assessments likely focus more heavily on issues of management, personnel, training, marketing, and quality assurance. Assessments of individuals and families emphasize biopsychosocial issues. Moreover, the agency auspices and mission will shape the breadth and depth of its assessment process and written reports. Historical Context It was Richmond’s (1917) quest to provide the profession scientific respectability that inspired her development of social diagnosis as the profession’s distinctive method, “the primary purpose of the writer, in attempting an examination of the initial process of social casework, is to make some advance toward a professional standard” (p. 26). This means of making sense of the client’s situation through use of evidence became the first identified component of social work practice: “social diagnosis is the attempt to arrive at as exact a definition as possible of the social situation and personality of a given client. The gathering of evidence, or investigation, begins the process, the critical examination and comparison of evidence follows, and last come its interpretation and the definition of the social difficulty” (p. 62). Outlining such systematic gathering of evidence, the facts from which judgments were made, broadened social work’s image from solely a charitable activity to its acceptance as a profession. Richmond provided rich detail

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about how to conduct the first client interview and gather further evidence from outside sources including medical providers, schools, friends and family members, employers, and others knowledgeable of the client. The interviews were to include thorough history-taking: “Social evidence, like that sought by the scientist or historian, includes all items which, however trifling or apparently irrelevant when regarded as isolated facts, may, when taken together, throw light upon the question at issue; namely as regards social work, the question what course of procedure will place this client in his right relation to society?” (Richmond, 1917, p. 39). Recognizing that the journey between social workers and their clients to determine the nature of the problem is one that is continuing and difficult, she states: “In social diagnosis, the kinds of evidence available, being largely testimonial in character, can of course never show a probative value equal to that of facts in the exact sciences” (p. 55). As we discussed in chapter 2, Richmond’s work to advance the profession was furthered by Abraham Flexner’s (1915) report to the National Conference of Charities and Corrections. In his comparison of the established professions of medicine, law and engineering, he found that social work lacked a distinctive method and scientific body of knowledge, although he commended its strong service orientation. After publication of Richmond’s book, Social Diagnosis, the group changed its name to the National Conference of Social Work more accurately to reflect its emphasis on social work as a profession and its retreat from charity and a religious base. During the depression years of the 1920s through 1930s, the psychosocial approach further evolved Richmond’s diagnostic method. Responding to criticisms that social diagnosis implied a medical or disease model of practice, Hamilton (1951) renamed it a psychosocial study. In later years, Hollis (1970) further developed the psychosocial approach: Social workers “must learn what the client sees as his problem,

what he thinks can be done about it, what he himself has tried to do about it, and what he sees as having brought about his present difficulty” (p. 46). Another approach, the problem-solving model, was developed by Perlman (1957). This problem-oriented method focused on developing a clear problem statement to direct the diagnosis and intervention (Bisman, 1999). Contemporary Perspectives The DSM and Labeling Chief of the many efforts to add specificity in assessments of individuals is the use of diagnostic categories from the Diagnostic and Statistical Manual of Mental Disorders (DSM). Seeking a common language and standardized criteria as well as a stronger scientific basis for mental disorders, it is now extensively used by many mental health professionals including social workers. Some of its enormous popularity, especially in the United States, is in part due to a diagnosisbased approach to insurance payment for service. Its proponents point to the positive impact classification has on research to improve treatments and monitor outcomes. The American Psychiatric Association (APA) published the first edition of the DSM in 1952; the fifth edition was released in 2013. Over these decades, debates have intensified about its value. Some, including Kirk and Reid (2002), have long criticized the labeling of mental disorders. Meyer (1993), critical about classification in general, states: “While classification is important, it also is extremely complex in fields like social work and mental health, because the human condition does not lend itself easily to discrete analysis, where one is able to select particular units or variables that describe complex biopsychosocial phenomena in reliable ways” (p. 94). Others raise concerns about the problematic effects of the labeling that often results from these diagnostic categories. It is easy for a diagnosis to become a label attached to and stigmatizing a human being wherein the person is treated as the label. As accepted jargon, such labels usually imply an intractable problem and

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mask lack of understanding gained by critical thinking and case theory development. Kirk and Hsieh (2009) find variance between a practitioner’s conception of mental disorder and the official DSM definition, and they suggest that researchers and practitioners work toward clarifying the concepts of disorder and dysfunction and develop and incorporate into the categories of the DSM appropriate indicators that have specificity, validity, and reliability of actual dysfunction; taking into account the social context of behavioral symptoms. Findings by Pottick, Wakefield, Kirk, and Tian (2003) indicate that training in use of the DSM influences perceptions of mental disorders with both positive as well as negative consequences. Again, we must keep in mind these categories are constructions to think about behaviors—no blood test indicates the existence of depression (at least at this point in time, although there are beginning efforts to establish physical evidence such as biomarkers, and the term predisposition has gained some acceptance). For an assessment to be of use and to make sense, social workers (and other mental health professionals) must be able to articulate the meaning of the mental disorder. In other words, although assessments can include diagnoses when they are available, the most important function of the assessment is to provide meaning of the diagnosis to increase understanding of the client’s overall functioning. Furthermore, distinctions must be clear between a chronic condition and normal reactions to stressful environments. These expectations of assessments demand serious attention by social workers who draw from the diagnostic categories to explain client problems. Contemporary practice does expect knowledge and use of these categories; they can be a helpful component in effective treatment (and until U.S. health reform toward the European/United Kingdom models succeeds, they are necessary for insurance reimbursement in the United States). While Munson (2002) reminds us that a long history of research preceded and continues

with DSM classification, Hardcastle et al. (2011) point to the narrowness of diagnosis. For them, assessment is preferable in community practice: it has “more inclusive and generic concepts with greater emphasis on social and environmental variables” (p. 14). Also emphasizing its importance, “we understand the life of a community through an assessment process. Assessment is the first and most important practice task” (p. 134). They caution role clarity: consulting for an agency may predispose us toward particular programs, while residing in a community may prejudice our perspectives. The choice of field methodology should reflect the purpose of the assessment. The work of Warren and Warren (1984), still the seminal approach for studying a neighborhood, is widely used in social work programs (more detail is included in the exercise at the end of this chapter). Other approaches to community assessments include surveys either written or phone interviews with a broad number of participants and community information gathering through advisory and focus groups. Community power structures might be the focus or particular problems such as an increase in crime or lack of services such as public transportation may demand attention. Likewise for agencies, assessment choices should also reflect the organization’s purpose and mission. Problems might include a shrinking client population, lack of funding, high staff turnover, and low staff morale (Hardcastle et al., 2011). Biopsychosocial Approach Reflecting an emphasis in the 1980s on the organic basis of disorders, social work has now broadened to a biopsychosocial approach, and the psychosocial study is now the biopsychosocial report. The inclusivity of these three primary domains recognizes that problems addressed by social workers are often a function of biological factors, psychological issues, and the social context. Among many other variables, the biological encompasses chemistry, neurology, genetics, physiology and effects of

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environmental factors; psychological includes cognitive, affective, and emotional functioning; social refers to social supports and interactions, community resources, as well as class issues of income, employment, and education. Nevertheless, although physiologic and psychological factors are necessary pieces of the social work assessment, understanding of the client’s social functioning should always be the social worker’s main focus recognizing the effects of the biological and psychological on the social. Many in society, both professional practitioners and laypersons, view mental disorders as different from those that are physical, despite ample evidence that mental illnesses are also physical, just as physical conditions have mental components. Kolata (2012) reports on the extraordinary research into tests for genetic sequencing leading to approaches for treating cancer that had been considered intractable. Dao (2013) discusses research to find biomarkers for posttraumatic stress disorder (PTSD), with hopes of expanding to other mental illnesses such as depression and psychosis. These efforts to test biologically for mental health problems similar to a cardiology test for heart disease, despite the far greater complexity of the brain, seek evidence other than self-report of symptoms. Lewontin (2011) raises the critical observation that there are many developmental and physiologic interactions that result in illnesses for some people and therefore cautions to not overly rely on one set of data. It is the case that while the mental is physical, the emotional is also psychological and physical. Categories are not easily defined and boundaries are difficult to establish (Angell, 2011). (See chapter 2 for fuller treatment of the shift to the biopsychosocial approach.) Evidence The movement for evidence-based practice (EBP) has sought to standardize practice by reducing reliance on authority, increasing rigorous appraisal of research, attending to actual symptoms rather than untested assumptions, and use of valid and reliable tools and

measurements. Bisman and Hardcastle (1999) emphasize the centrality of measurement and research approaches for effective practice: member-checking (acquiring perspectives from a range of informants including those close to the client and colleagues at the setting), along with a form of such checking, respondent validation (discussion with clients about the meaning of events allows practitioners and clients to share a construction of reality). Triangulation (gathering multiple sources of information) is another research tool critical for practice to develop case theories that are reliable (consistent and cohesive) and valid (accurate). Such approaches reduce reflexivity, where the measurement process changes what is being measured, and bias, where the measurement (often the person measuring) gets inaccurate information. Gambrill (2006) points to the importance of critical thinking skills in constructing assessments based on evidence of value to clients: “Critical appraisal of assessment frameworks can help us to discover the extent to which different views enhance the likelihood of selecting effective plans” (p. 326). Hypotheses draw from both deduction (drawing ideas from broad concepts) and induction (generalizing from specific events). As we cautioned in an earlier chapter, social workers must guard against fallacious thinking and circular reasoning. Decisions about the type of problem confronting the client determine the range of theories utilized to both understand and to create change. We will see throughout this chapter the importance of obtaining and using evidence for assessments that is valid and relevant to the client’s situation and will consider approaches to help eliminate bias and assumptions that contaminate evidence, potentially causing harm. Assessment Tools and Models There are a range of tools and models to help concretize the assessment process. The following two tools, ecomaps and genograms, are easily adaptable

EVIDENCE FOR KNOWLEDGE-GUIDED ASSESSMENTS

to changes for different settings and different client populations. Ecomaps identify not only the actual social interactions between a client system (usually individuals or families) with its social environment but also include areas of stress as well as positive supports. Hardcastle et al. (2011) explain these as a “mapping of relationships between community assets that are part of a household’s environment or ecology” (p. 172). The typical approach for this simple paper and pencil drawing (Hartman & Laird, 1983) is to place the client system in a circle in the middle of the page, then surround that circle with other social systems with which the client interacts. These might include schools, health, neighborhood, friends, family, work, child care, courts, police, and so forth. Each of these circles can have other circles intersecting. For example, an individual might draw off her family circle several intersecting circles to depict the various family systems (an elderly parent who is dying, siblings, and children). The nature of these interactions are indicated by lines: >>>> indicates energy from the client going to the social system, whereas