The Life Model of Social Work Practice: Advances in Theory and Practice 9780231547291

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THE LIFE MODEL OF SOCIAL WORK PRACTICE

The Life Model of Social Work Practice Advances in Theory and Practice FOURTH EDITION

Alex Gitterman, Carolyn Knight, and Carel B. Germain

Columbia University Press

New York

Columbia University Press Publishers Since 1893 New York Chichester, West Sussex cup.columbia.edu Copyright © 2021 Columbia University Press All rights reserved First edition published 1980 Second edition published 1996 Third edition published 2008 Library of Congress Cataloging-in-Publication Data Names: Gitterman, Alex, 1938- author. | Germain, Carel B., author. | Knight, Carolyn (Professor), author. Title: The life model of social work practice : advances in theory and practice / Alex Gitterman, Carel B. Germain, Carolyn Knight. Description: Fourth Edition. | New York : Columbia University Press, 2020. | Revised edition of The life model of social work practice, c2008. | Includes bibliographical references and index. Identifiers: LCCN 2020012586 (print) | LCCN 2020012587 (ebook) | ISBN 9780231187480 (hardback) | ISBN 9780231547291 (ebook) Subjects: LCSH: Social case work. | Human beings—Effect of environment on. Classification: LCC HV43 .G47 2020 (print) | LCC HV43 (ebook) | DDC 361.3/2—dc23 LC record available at https://lccn.loc.gov/2020012586 LC ebook record available at https://lccn.loc.gov/2020012587

Columbia University Press books are printed on permanent and durable acid-free paper. Printed in the United States of America

I, Alex, dedicate the book to Professor Carel Bailey Germain, who died on August 3, 1995, just as we were editing the final manuscript of the second edition. Our collaboration began in 1972 as faculty colleagues developing the first integrated practice course at the Columbia University School of Social Work. This led to a 23-year writing collaboration and close friendship. The effort to develop and express our ideas about practice forged an enduring bond between us. Professor Germain was internationally recognized for her brilliant scholarship. She drew on numerous academic disciplines to develop ideas about human ecology. Her body of work reflects an uncommon intellect and erudition. She has bequeathed a lasting gift to the profession. Professor Germain held fast to her ideas, never cutting her cloth to suit the fashion of the day. She was graceful, gentle, and gallant. Her understated wit was illuminating and often trenchant. The epilogue in our second edition ended with, “And so our journey continues!” Without Carel, the journey has been lonelier, but her originality, powerful ideas, and loyalty have been sources of continuing strength. I, Carolyn, dedicate the book to the many clients I have worked with over the years. It has been a privilege to have accompanied them on their journey through pain and despair, powerlessness and loss to healing, self-discovery, and empowerment. I have been both humbled and deeply inspired by their quiet strength and resilience in the face of often insurmountable odds. They, like my students, have taught me so much, and I am deeply and forever indebted to them.

Contents

Preface Note to Instructors Acknowledgments

ix xv xvii

PART I: Overview 1 2 3 4 5

Social Work Practice and Its Historical Traditions The Ecological Perspective The Life Model of Social Work Practice: An Overview Culturally Competent and Diversity-Sensitive Practice and Cultural Humility Assessment, Evidence-Guided Practice, and Practice Evaluation

5 54 82 114 143

Part II: The Helping Process in Life-Modeled Practice Initial Phase 6 Preparation: Settings, Modalities, Methods, and Skills 7 Beginnings: Settings, Modalities, Methods, and Skills

177 217

CONTENTS

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Ongoing Phase 8 Helping Individuals, Families, and Groups with Stressful Life

Transitions and Traumatic Events 9 Helping Individuals, Families, and Groups with Environmental Stressors 10 Helping Family Members with Maladaptive Communication and Relationship Patterns 11 Helping Group Members with Maladaptive Communication and Relationship Patterns 12 Helping with Maladaptive Relationship and Communication Patterns between Social Workers and Clients Ending Phase 13 Endings: Settings, Modalities, Methods, and Skills

258 310 365 419 469

509

Part III: Life-Modeled Practice at the Community, Organizational, and Political Levels 14 Influencing Community and Neighborhood Life 15 Influencing the Practitioner’s Organization 16 Influencing Legislation, Regulations, and Electoral Politics

545 581 614

Appendix A: Individual, Family, and Group Assessments Appendix B: Practice Monitoring—Records of Service Appendix C: Practice Monitoring—Critical Incidents Appendix D: Force Field Analysis Notes References Index

643 657 663 679 683 687 719

Preface

For Professors Germain and Gitterman, the first edition of the Life Model symbolized a long, adventurous journey. It began in 1972 at the Columbia University School of Social Work, when they and another colleague, Professor Mary Funnyé Goldson, were asked by the dean to develop a plan for the first year of social work practice courses. Earlier, the faculty had decided to restructure the total curriculum to take into account emerging knowledge, new human needs, and developments occurring in practice itself, as agencies sought to meet the challenges of that era. This led to our effort to reconceptualize practice and to develop an integrated social work practice method. Out of this joint work on a first-year practice curriculum came our further collaboration in workshops, consultations, and writing. We found that ecological ideas helped us understand how each of us became a source of learning for the other. Sometimes our different professional traditions, knowledge base, and practice experiences felt like barriers to mutual understanding, but they actually facilitated and enriched the development of our ideas. The first edition represented a beginning attempt to work out the dimensions of integrated method practice with individuals, families, groups, social networks, and organizations. Our ideas rested on the assumption that

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there are many common methods and skills in direct practice, no matter on what level people are organized. The first edition also attempted to identify distinctive methods and skills such as those used in forming groups or influencing organizations. The common as well as distinctive methods and skills were presented within an ecological perspective that offered a dual, simultaneous focus on people and environments. These skills were presented within the context of underlying diverse theories and knowledge at each level of human organization—individual, family, group, social networks, bureaucratic systems, and the physical environment. The first edition of The Life Model of Social Work Practice was published in 1980, and sixteen years later (1996), the second edition appeared. Professor Germain died just as we were editing the final manuscript. From our collaborative effort to develop and express our ideas about practice over twenty-three years, we had forged an enduring bond. She was a brilliant, internationally renowned scholar who drew on different disciplines to develop her ideas about human ecology. Her body of work reflects an uncommon intellect and erudition. She bequeaths a lasting gift to the profession. The third edition was published twelve years later, in 2008. Preparing this edition without Professor Germain was a difficult challenge, but the endeavor was fueled by the belief that we both shared that the profession of social work was more necessary and more complex than ever. The third edition had important new content. A reintroduced historical chapter included an examination of the settlement house and charity organization societies (COS) movements’ lack of responsiveness to people of color. In order to fill the void left by these two movements, building on the African American self-help and mutual aid traditions, African American leaders duplicated and created a parallel social service system for their own communities. The contributions of these black leaders are discussed. A new chapter, called “Assessment, Practice Monitoring, and Practice Evaluation,” examined the assessment tasks common to all practice approaches, as well as a few underlying beliefs that are distinct to life-modeled practice. The chapter also examines the tasks and skills of practice monitoring, as well as the strengths and limitations of different research designs used to evaluate practice outcomes. Another new chapter, “Preparation: Settings, Modalities, Methods, and Skills,” examined the professional processes of skillfully entering clients’ lives. Clients must feel safe and accepted before they can trust and confide in a professional. Other chapters were updated. The publisher periodically inquired about and requested a fourth edition. Alex pondered whether a fourth edition was actually needed. The question was answered by dramatic changes in the geopolitical and socioeconomic landscape

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that have profoundly affected the lives of individuals, and therefore the practice of social work. Global warming and its devastating consequences, international trade agreements, terrorism, a conservative revolution, the election of U.S. president Donald Trump, a disappearing middle class, and the growing gap between the rich and poor, sexism, racism, Black Lives Matter, gun violence (especially mass shootings), technology, and repressive immigration policies have transformed the lives of people in the United States (and certainly elsewhere as well). Incorporating these kinds of life-changing developments into the book was essential to enrich the content and heighten its relevance to contemporary practice. Practice and education for practice must be consonant with new knowledge, new needs, new social conditions, cultural diversity, and the search for an end to oppression. Alex undertook the third edition with much sadness, knowing that he would miss Carel’s intellectual stimulation and support, as well as their exchanges of ideas. However, he was comforted by the knowledge that Carel wanted him to continue their journey and that she would be with him in spirit. In contrast, Alex undertook the fourth edition with much excitement, as Professor Carolyn Knight, a brilliant colleague and close friend, agreed to join him on the continuing journey. In the last few years, Carolyn and Alex have coauthored numerous articles that have been published in top-tier professional journals. We have developed a very comfortable collaboration. Her expertise in trauma, particularly sexual abuse, as well as her work in a residential shelter for homeless families, were significant resources for us to draw upon. In the fourth edition, we remain committed to the Life Model’s original conceptions and attempted to broaden and deepen them. The ecological metaphor continues to provide the indispensible concepts that illuminate the continuous exchanges between people and their environments. The ecological perspective has been embraced by the profession and will continue to “drive” this edition. Since its first explication in the 1980 edition, the profession has embraced the dual perspective of both persons and environments. Both the National Association of Social Workers (NASW) and the Council on Social Work Education (CSWE) have taken similar positions: What distinguishes social work from other human service professions is its location in the people-environment interface, where exchanges between the two influence and shape one another. The new edition will attempt to provide a clearer exposition of the ecological perspective and its application to social work practice with diverse populations in varied settings. In contrast to traditional stage models of development, the fourth edition further develops the life course formulation, which takes into account diversity

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in race, ethnicity, sex, age, socioeconomic status, sexual orientation, physical/ mental challenges, and environmental forces within historical, societal, and cultural contexts. The life course formulation replaced the traditional, linear life cycle models and their assumption that emotional and social development proceed in fixed, sequential, universal stages, without referring to the diversity of life experiences, cultures, and environments. This edition also continues to refine an integrated practice. The assumption continues to be that professional specialization should not determine whether a client receives individual, family, group, or community services, but rather that the service should be driven by client needs and preferences. Two formulations continue to be particularly helpful in developing an integrated life-modeled practice.1 The first, degree of client choice, differentiates common professional methods and skills in the initial phase by how much choice an individual, family, or group has in accepting or rejecting a social work service (i.e., whether the client sought the service or an agency offered or mandated a service) rather than by a particular modality. The second, life stressors–stress–coping, supports an integrated practice related to the assessment of and intervention with varied life stressors rather than to an agency’s service mode. Life stressors and associated stress include (1) difficult life transitions and traumatic life events, (2) social and physical environments, and (3) maladaptive interpersonal processes in families and groups, and between workers and clients. Research and practice reveal that managing a life stressor of any kind can involve simultaneous changes in (1) social, psychological, and biological functioning; (2) interpersonal processes; and (3) altered environmental processes requiring new responses. While we realize that any separation of phenomena distorts the reality of simultaneous processes, we think that analyzing them separately has distinct advantages. Social work practitioners are overwhelmed by the nature, range, and intractability of life stressors faced by the people they serve. The life stressor– stress–coping paradigm covers an almost limitless variety of human plights and provides a useful schema for specifying, grouping, and organizing data throughout the helping process. The paradigm also provides heuristic guidelines that focus and direct interventions at any point during the helping encounter. It also links clinical practice with practice in growth-promotion and prevention programs. We caution readers that life stressors often must be managed simultaneously or, at least, any one of them may need to be managed in such a way as to have a positive impact on the others. Life-modeled practice is committed to responding constructively to changes within the profession and in pertinent new theory and research findings, as well as to increases in human and environmental diversity. We will continue

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the quest for ever-broadening understanding of, and respect for, the endless variety of human strengths, exemplified in the lives of all those whom social work serves. This commitment rooted in the evolving, adaptive nature of the Life Model, helps ready its practitioners to meet new and old demands in the twenty-first century. To this end, we use new concepts and new content. We have added new content on trauma-informed practice in almost every chapter. Chapter 4, “Culturally Competent and Diversity-Sensitive Practice and Cultural Humility,” has been added to increase understanding, sensitivity, and skills in helping diverse populations. We incorporate and rely upon our alternative approach to evidence-based practice, evidence-guided practice (Gitterman & Knight, 2013). Our approach represents a synthesis of current notions of evidence-based practice with the ethical mandates of the profession and its commitment to cultural humility and competence. Throughout the book, we incorporate relevant research findings. The oppression experienced by many of those we serve leaves their families, networks, and communities vulnerable to deprivation and deterioration. These realities have required us to work more intensely on building bridges between the clinical and social reform traditions of the profession. Social workers whose practice is life-modeled must be increasingly engaged in organizational, community, or neighborhood and policy practice. When working with individuals, families, and groups, many life-modeled practitioners expand their practice to populations of similarly affected persons, helping them to undertake social action and develop preventive and growth-promoting programs. We continue to make a determined effort in this book to explore the connections between people’s life stressors (“private troubles”), and community, organizational, and legislative influence and change (“public issues”). The book is divided into three parts. Part I offers a historical, theoretical and methodological overview. Chapter 1 traces social work’s historical dialectics such as cause or function (social action or clinical treatment), generalist or specialist, and science or art. The current societal context, (economic, political, legislative and cultural), and its impact on current professional developments is explored. Chapter 2 reviews the theoretical perspective, including concepts from deep ecology and ecofeminism. Chapter 3 presents the defining characteristics and anatomy of life-modeled practice at this point in its development. It briefly delineates modalities, methods, and skills used to help people to cope with or meliorate life stressors. Chapter 4 emphasizes that one needs to understand the values, traditions, social reality, and challenges of individuals with a shared cultural identity. The concept of cultural humility reminds us that to achieve competence, social workers must remain humble and curious and devote their

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careers to strive for understanding the world view and social realities of others. Chapter 5 examines assessment tasks common to all practice approaches, as well as a few underlying beliefs that are distinct to life-modeled practice. It also examines the tasks and skills of practice monitoring, as well as the strengths and limitations of different research designs used to evaluate practice outcomes. Part II presents the knowledge, values, methods, and skills of life-modeled practice with individuals, families, formed groups, organizations, and social networks. Chapter 6 examines the professional processes of skillfully entering people’s lives. People must feel safe and accepted before they can trust and confide in a professional. The chapter also examines the essential preparatory tasks in forming a group and in selecting the appropriate modality and temporal arrangement. Chapter 7 considers the initial phase of working together (i.e., of getting started with individuals and collectivities). All helping rests on shared definitions about life stressors and explicit agreement on goals, plans, and methods. Chapters 8 through 12 cover the ongoing phase. Specifically, chapter 8 discusses the distinctive knowledge and skills of helping individuals and collectivities deal with painful life changes. Chapter 9 considers the interrelated dimensions of helping individuals and collectivities negotiate their organizational, social network, and spatial and temporal environments. Chapters 10 and 11 explore the issues of helping families and groups deal with maladaptive interpersonal processes that prevent the fulfillment of members’ individual and shared needs. Chapter 12 explores interpersonal stress in the worker-client relationship, particularly the processes that interfere with helpfulness. Chapter 13 considers the ending phase, or termination of the work together, and evaluation of practice. Part III examines life-modeled practice at community, organizational, and policy levels. Chapter 14 focuses on helping communities and neighborhoods to achieve desired improvement in their quality of life. Chapter 15 discusses professional issues and methods of influencing organizational operations that do not serve their intended beneficiaries. Chapter 16 embraces the commitment to a just society through the participation of practitioners in political activity. Social work’s purpose and its value system require us to help change the oppressive life conditions of many clients. We therefore regard community, organizational, and political advocacy for social justice as the responsibility of all social workers.

Note to Instructors

We have provided you with a teaching guide that you may access using the following link: http://www.cup.columbia.edu/extras. In the first section of the guide, we present general educational concepts and teaching strategies we have found useful in creating a learning environment that releases students’ potential for professional development. We identify teaching techniques that promote discussion and foster students’ critical thinking abilities and willingness to engage in self-reflection. We also describe how to effectively use a lecture format to present material in a way that captures students’ interest. We base our discussion on the belief that students learn from what their teachers say as well as what they do. When instructors employ in the classroom the skills that they are teaching and that we present in the text, they serve as powerful role models to their students and create a learning environment that promotes students’ learning. Part II of the guide summarizes the content for each chapter, and we note where each of the nine CSWE competencies and their associated practice behaviors are addressed. We believe that instructors must tailor their presentation of the material to the uniqueness of: their students, their teaching style, and the sociocultural environment within which their institution is located. We provide

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general guidelines for how to present the material, propose questions for class discussion, and suggest assignments that help students engage in critical thinking and integration of theory and research with their practice. But we want instructors to use these suggestions flexibly and creatively and in a way that reflects their distinctive educational context.

Acknowledgments

We are deeply grateful to our baccalaureate, masters, doctoral students, seminar participants, practitioners and our clients—all from whom we have learned a great deal. We especially appreciate the remarkable richness and relevance of their materials to the social issues facing our society and to the struggles of our profession to meet increasingly complex human needs. We literally could not have written this book without these individuals’ willingness to open up their work and themselves to appraisal and analysis. Alex thanks Professors Toby Berman Rossi, Diane Drachman, Naomi Gitterman, Mary Funnyé Goldson, Ann Hartman, Nina Heller, Steven Holloway, Nancy Humphreys, Carolyn Knight, Joan Laird, Judith A. B. Lee, Jacqueline Mondros, Lawrence Shulman, Renee Solomon and Julianne Wayne for sharing their creativity and practice acumen over many years. Alex also expresses deep gratitude to his late, beloved, mentors, faculty colleagues and friends, George Brager, Richard Cloward, Carel B. Germain, Irving Miller, William Schwartz, and Hyman J. Weiner for their remarkable contributions to social work theory and practice. Their ideas continue to influence the profession and my own work. Carolyn also thanks Toby Berman Rossi and Lawrence Shulman for generously sharing their practice wisdom. Most important she thanks Alex Gitterman

ACKNOWLEDGMENTS

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for providing her with the opportunity to work with him to update and revise this text. I taught my first social work practice course in 1985, which is when I was first introduced to The Life Model of Social Work Practice. This text quite literally opened my eyes to what it really meant to be a social worker. I had my MSW, was pursuing my PhD in social work, and had been a practicing social worker for several years. Intuitively, I was operating from an ecological and life-modeled perspective. Yet, I lacked a theoretical framework to guide me in my work. The Life Model provided me with a frame of reference that I desperately needed, allowing me to more purposefully and effectively intervene in clients’ lives. It truly has been an honor to work alongside Alex, my friend and mentor. I hope that, like its predecessors, the fourth edition provides guidance to and inspires the next generation of social workers. Finally, we are grateful to our families for their love and support. Alex is grateful for the professional contributions of his wife, Naomi, as well as her abiding love and support and that of their children, Daniel and Sharon, daughter-in-law, Amy, grandchildren, Max and Claire. In their distinctive way, Alex’s late mother, stepfather and father, (Fay, Pincus and Aaron), aunt, (Maria), and late mother-in-law, (Ilse), taught him the meaning of courage and the value of life. Carolyn: I have been blessed to be surrounded by family and friends who have loved me and been by my side throughout my life. Writing this book has brought home to me in a powerful and poignant way how essential a supportive social network is for us as human beings. Memories of loved ones I have lost—my parents and grandparents—continue to sustain me and provide me with comfort. My close network of family and friends, particularly my husband, Herb, my son, Colin, and his new wife, Kristin, enrich my life every day. For that, I am deeply grateful. Carel was always grateful for the love and devotion of her husband, William, and daughters, Adrienne and Denise. She was also extremely proud of her daughters’ significant professional accomplishments, and most of all, of their humanity.

THE LIFE MODEL OF SOCIAL WORK PRACTICE

Overview

PA R T I

Part I introduces the historical context for the Life Model of Social Work Practice. The current conceptual framework of the ecological perspective for social work practice follows the historical perspective. A brief overview of life-modeled practice and its defining features, modalities, methods, and skills also is presented. It concludes with a discussion of assessment, practice monitoring, and practice evaluation. Chapter 1 traces themes and trends in the historical development of the social work profession’s purposes and methods in the United States. Particular attention is paid to the historical dialectics, such as cause-function (social action–clinical treatment), generalist-specialist, and the science and art of practice. The current societal context (economic, political, legislative, and cultural), as well as its impact on current professional practices, are explored. Chapter 2 reviews the major ecological concepts that underlie life-modeled practice: 1. The reciprocity of person:environment exchanges, in which each shapes and influences the other over time. We intentionally use the colon rather than the

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more commonly used hyphen, which suggests a less balanced relationship between individuals and their environment. 2. The levels of fit between people’s needs, goals, and rights and their environment’s qualities and processes within a historical and cultural context. We explore adaptedness and adaptation (which results from making changes in the self, the environment, or both) to improve or sustain the level of fit; maladaptiveness, which results in unconstructive perceptions, emotions, thinking, and action; and positive and negative feedback processes. 3. Beneficial and nonbeneficial human habitats and niches. 4. Vulnerability, oppression, abuse or misuse of power, and social and technological pollution. 5. The “life course” concept of nonuniform pathways to human development and functioning. This perspective replaces traditional formulations that consider human development a journey through fixed, sequential, and universal stages and incorporates human, environmental, and cultural diversity, and it is applicable to individuals and groups. It also uses temporal concepts—historic, social, and individual time—to consider psychosocial functioning. 6. Life stressors that threaten the level of fit and lead to associated emotional or physiological stress. We identify the coping tasks that require personal skills and environmental resources for managing life stressors and reducing the associated stress. 7. Resilience, which reflects the ongoing consequences and outcomes of complex person:environment transactions. We discuss protective factors that help people to negotiate challenging situations, as well as variables that place people at greater risk in these situations. 8. Deep ecology, a perspective that assumes that all phenomena are interconnected and interdependent, as well as dependent on the cyclical processes of nature. We discuss the three basic principles of deep ecology: the interdependence of networks, self-correcting feedback loops, and the cyclical nature of ecological processes. 9. Ecological feminism, or ecofeminism, a perspective that challenges the culture/ nature dichotomy. Oppression of women and ecological degradation are intertwined, as both evolve from hierarchical male domination.

Chapter 3 provides a brief overview of the origins and characteristics of life-modeled practice. Ten features, in unique combinations, define life-modeled practice: (1) professional purpose and function, which includes practice with individuals, families, groups, communities, and organizational and political advocacy; (2) ethical practice; (3) diversity-sensitive and culturally competent

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practice; (4) empowering and social justice practice; (5) integrated modalities, methods, and skills; (6) a client: worker relationship framed as a partnership; (7) agreements, assessments, and life stories; (8) focus on clients’ personal and collective strengths and their actions and decision-making; (9) pervasive significance of social and physical environments and culture; and (10) evaluation of practice and contribution to knowledge-building. The preparatory, initial, ongoing, and ending phases of work organize life-modeled practice, even in one-session and episodic services, where the phases may be temporally collapsed. Life-modeled practice focuses on (1) painful life transitions and traumatic life events; (2) poverty, oppression, and unresponsiveness or harshness of social and physical environments; and (3) maladaptive interpersonal processes in families and groups, and sometimes also between practitioners and clients and between clients and the organizations designed to help them. These and many other aspects are considered in greater detail and depth in parts II and III. Chapter 4 considers the significance of cultural factors in a person’s life. Understanding and respecting clients’ cultural and social identities in ways that are meaningful for them is an essential feature of life-modeled practice. Cultural competence begins with an understanding of the values, traditions, social reality, and challenges of individuals with a shared cultural or social identity. Life-modeled practitioners acquire knowledge about a group of people who share certain characteristics, but they also respect the diversity within the group. The social world our clients inhabit is far more complex and dynamic than simply learning about a specific culture. Life-modeled social workers invite and listen to their clients’ life stories and perceive their clients as the experts on their lives and social realities. Chapter 5 examines assessment tasks common to all practice approaches, as well as underlying beliefs that are distinct to life-modeled practice. Lifemodeled practice strongly values and encourages client participation in the assessment tasks and emphasizes assessment of the level of fit between human needs and environmental resources. Graphic representations, including ecomaps, genograms, and social network maps, and force-field analysis provide a visual “snapshot” of individuals, families, groups, communities, social networks, and organizations and their capacities to deal with stressors and change. The chapter also examines the tasks and skills of practice monitoring. Practice interventions must be evaluated by how clients experience and evaluate their relevance to and helpfulness in their lives, rather than by what practitioners intend to accomplish. We discuss and illustrate various practice-monitoring instruments. The chapter concludes with an examination of the strengths and limitations of various research approaches used to evaluate practice outcomes.

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We hope that the examination of the historical context and contemporary societal and professional themes, ecological concepts, and overview of the totality of life-modeled practice and issues related to assessment, practice monitoring, and practice evaluation in part I will help the reader move confidently and eagerly into parts II and III, with their detailed study of the complexities of professional practice. Parts II and III are designed to prepare students and seasoned practitioners to move knowledgeably and skillfully among varied modalities (individual, family, group, neighborhood and community, organizational, and political) as needed.

Social Work Practice and

ONE

Its Historical Traditions

The generalist and integrative methods of the life model of practice are both an outcome of historical trends and a response to current issues within the profession. New or emerging forms of practice must be understood in the light of professional traditions that have spurred their development and of demands placed upon the social work profession by external forces in its environment and internal forces within the profession—both the past and the present shape contemporary social work practice. In this chapter, we trace important themes and trends in the historical development in the United States of social work’s practice, purposes, and methods.

EARLY SOCIETAL AND PROFESSIONAL THEMES Progressive Era (1880–1920)

The twin forces of industrialization and urbanization were accompanied by severe social disorganization. Industrialization led to the concentration of wealth and power and the growing alienation of labor. Persistent poverty was aggravated

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by cyclical economic depressions. Substandard housing, inadequate schools, and oppressive work arrangements characterized crowded urban slums and poor rural areas. The federal government itself favored (and was, in fact, in thrall to) the nation’s business interests. The principle of laissez-faire was for the poor; the principle of free enterprise advanced the interests of the rich, the powerful, and the white; and the Supreme Court upheld property rights at the expense of human rights. Despite the abolishment of slavery more than a decade earlier, it continued to have a devastating impact on black citizens. In addition, more and more of society’s dependent classes—paupers, the insane, and criminal groups—came under the aegis of state administration, often through boards of charities, insane asylums, and prisons. Child-saving agencies and voluntary associations for relieving the plight of the poor appeared in the private arena. A number of persons who were engaged in such public or private work joined with a group of New England intellectuals to organize the American Social Science Association (ASSA) in 1865. The interest of the ASSA intellectuals lay in developing knowledge that would lead to changing unacceptable social conditions. By contrast, the interest of those directly engaged in the care and control of society’s so-called misfits lay in developing the best methods for their control, care, and containment. This latter group considered that their concerns about pressing current social problems were being overlooked by the emphasis of the former group on theory development geared toward achieving uncertain gains in an unknown future. In 1874, the practice people withdrew from the ASSA and established the Conference of Charities (CC), which in 1879 became the National Conference of Charities and Corrections (NCCC), and subsequently the National Conference on Social Welfare (NCSW). The term “corrections” reflected this practice arena, but it also reflected a growing desire to change people as well as provide charity. The roots of direct social work practice can be traced to the NCSW. Several currents of conflicting ideas appeared within the NCSW, and even within each current there was little unanimity of opinion. One stream of ideas was associated with the Poor Law philosophy and included the principle of less eligibility (conditions in a poor house had to be worse than those outside of it) and the settlement laws (which based eligibility for relief upon strict residency requirements). These notions reflected a concern that charity might lead the needy into pauperism by weakening their moral fiber and were reinforced by the Puritan ethic, which viewed dependency as the consequence of sin, and the Calvinistic emphases on work and individualism. It was an ambivalent stance, however, since there were strong threads of piety involved, especially in attitudes

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toward the poor. There was a humane concern for the suffering of others, as in the parable of the Good Samaritan. A stronger thread was the promise of salvation through the giving of alms. In this view, the poor existed so that the rich might give to them, receive grace, and enter the Kingdom of Heaven. A second ideological current was a growing interest in science and its promise of unlimited progress through knowledge and technology. It was this interest, coupled with idealistic reformism, that had led to the establishment of the ASSA. The ASSA intellectuals, and later some groups within the NCCC, assumed that there were laws that governed the social order just like those that governed the physical world. Once discovered, such laws could be used to create a better society. The purpose of social science was to discover and understand these laws. Many who held this conviction also believed that environmental causes were more salient than personal weakness in understanding most forms of human distress. In general, the theoreticians believed that the cause of human distress lay in the environment, while the methodologists believed that causality was to be found in the wickedness, shiftlessness, and weakness of individuals. Connected to the interest in science, yet ultimately nonscientific in outlook was the rise of Social Darwinism, which inaccurately applied Charles Darwin’s ideas about biological evolution to societal processes. Social Darwinism provided a rationalization for the exploitation of the powerless by the powerful. Political thought, interacting with capitalistic developments, became increasingly dominated by conservatism and its emphasis on economic freedom and the sanctity of private property. Political, philosophical, religious, and pseudoscientific ideas thus combined to help create a point of view in society that opposed environmental reform. In search of employment opportunities and an improved quality of life, African Americans migrated from the South and whites from different ethnic groups emigrated from Europe to Northern and Midwestern urban centers. These migrants and immigrants provided inexpensive labor for industries and factories. By 1914, the workforce was seven times that of the workforce in 1859. Similarly, in the 1880s, only 28.7 percent of the population in the United States lived in urban areas, as compared to 35.1 percent in the early 1900s. By 1920, the overall population had increased to more than 105 million, with 51.2 percent living in urban areas (Iglehart & Becerra, 2000). Many social problems such as slums and crime became associated with this dramatic urban population growth. In response to these social problems, the settlement house movement, which began in the United States in 1886, and charity organization societies (COSs), which began in 1887, appeared almost simultaneously. Each reflected ideas that originated in Victorian England. Both movements spread rapidly around the

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country and, although they took somewhat different ideological positions and different practice outlooks, they possessed important similarities. Both appealed to young, upper- and middle-class, well-educated idealists of the day, and most especially to young women. Higher education for women had only just begun on any recognizable scale, and a new group of young women students and graduates were eager to be of service. They were looking for ways to apply their newly acquired insights and understanding to society’s growing problems, as well as ways to become financially independent. Both movements had a strong religious cast. Many COS secretaries, especially in the early years, and settlement head residents were ministers. Most were Protestants, but later there were also Catholic and Jewish settlements, as well as sectarian charitable associations. Deeply committed to serving others, both the COS and the settlement groups believed they had found the structure that would solve the social problems of their era. The leaders of the COS movement, Mary Richmond, and the settlement movement, Jane Addams, were committed to social reform. Richmond distinguished two types of social reform: wholesale and retail reform. The settlements participated in wholesale reform; the COSs in retail reform. Despite their similarities, however, the differences between the two movements were to have a profound effect on the dialectical development of social work practice. The Settlement House Movement

To the founders of the settlements, the sources of most urban misery lay in the environment. To live among the poor, sharing their joys and sorrows, their struggles and toils, was to be a good neighbor. The “settlers,” as they called themselves, asserted that their work was not charity but good neighboring, and so they worked to provide such amenities as clubs for boys and girls, classes for adults, and summer experiences in the country for both children and adults. For the settlers, conflict between the classes stemmed from a lack of understanding, and thus they needed to relate to each other. Such interaction between the poor and the settlers would improve the former, and through their interactions, people would begin to understand each other and resolve their conflicts. The settlement workers’ devotion to democratic and liberal social philosophy went hand-in-hand with an abhorrence of anything that smacked of charity and what the workers saw as charity workers’ stinginess in the face of need. In times of economic depression, neighboring included creating work projects for individuals who had lost their jobs and had no way to provide for their families.

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The required investigation and verification of need, however, were repugnant functions to the settlers, and they considered them appropriate only in times of great emergency. The settlers soon concluded that their well-intentioned efforts to improve the quality of life for their working-class neighbors were minimally effective in reducing the hardships imposed by the nature of the physical and social environments. They became intensely aware of tenement conditions, lack of sanitation, poor schools, inadequate play space, long working hours in factories and sweatshop industries, child labor, and the many obstacles faced by immigrant populations in their attempts to adapt to their new environment. The interests of the settlers broadened to include the painstaking collection of data and careful social research to support their legislative activities on behalf of environmental reforms. Increasingly, settlement residents aligned themselves with the Women’s Trade Union League. They supported the strikes of organized labor. They were instrumental in forming the consumer movement that worked to improve working conditions through boycotts. They played a significant role in the early women’s movement. They worked for sanitation, tenement reform, the playground movement, and child labor legislation (Addams, 1910, 1930; Wald, 1915). They were in the vanguard of social reform during the Progressive Era until its end in World War I. Many worked for the unpopular peace movement of the time, and Jane Addams of Hull House, severely criticized during World War I, received the Nobel Peace Prize many years later in 1931 for these very efforts. She was very involved in political activities, including seconding Teddy Roosevelt’s nomination as the candidate of the Bull Moose Party, and serving on the drafting committee of the party’s platform. From the beginning, the settlers were affiliated with colleges and universities, and sometimes were based in them. Graham Taylor of the Chicago Commons, with the help of Jane Addams and others from Hull House, established the Chicago School of Civics and Philanthropy, which in 1920 became the University of Chicago’s School of Social Service Administration. Settlement connections to the social scientists of the day were strong. For example, John Dewey and his friend and colleague, James Tufts, were frequent visitors at Hull House, and Jane Addams often referred to their influence. Dewey’s philosophy (1916, 1938) of pragmatism, his interest in the experimentalism of science and the instrumentalism of ideas, reintroduced humanistic values into the materialism of the times and profoundly influenced the settlement leaders. Other social scientists lived and worked in the settlements around the country to gain experience and to collect social data concerning community and neighborhood problems. Still

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others came as guests to conduct classes for residents and neighbors. While the settlement leaders embraced social science, some were ambivalent, and others rabidly opposed the idea of becoming professionalized. With the end of the Progressive Era, the settlement movement lost its momentum. Although some reforms were achieved after the war, the settlers were never again as powerful, and they remained outside the mainstream of practice and theory developments. Their objections and resistance to professionalizing their practice diminished their potential contributions to practice and theory. The Charity Organization Society Movement

The COSs, whose philosophy was characterized by the watchword “scientific philanthropy,” required the careful study of each application for aid, the development of central registration procedures, and coordination among charity organizations. This objective was to be achieved by organizing the various charitable organizations within a community in order to eliminate duplication and fraud. Methods were designed to separate the unworthy poor from the worthy and included verification of need, registration, classification, conferencing, and written records. The unworthy poor were deemed to be the responsibility of public indoor (i.e., institutional) relief, while the worthy poor (victims of circumstance, such as widows with children) were considered deserving of outdoor (i.e., in their own home) aid provided by privately sponsored charitable agencies. Charity had to be provided in a manner that would not foster dependency. Because there was constant apprehension that alms might destroy the individual’s drive toward independence, an important additional component of COS method was the “friendly visitor.” Where possible, help was to be “not alms, but a friend.” When alms were needed, such help would be given in conjunction with the services of the friendly visitor. Possessing middle- and upper-class values, the visitor provided an example that the poor could aspire to become. Like the settlement residents, the friendly visitors were volunteers, and a paid agent or secretary directed their work. Some university faculty were affiliated with COSs, seeing them as laboratories for the development of sociological knowledge, and some college and university students served as friendly visitors. The emphasis within COSs, however, was on developing the most effective methods of rehabilitating the poor one by one, while relatively little attention was given to uncovering environmental causes of poverty. Nevertheless, some COS leaders were

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deeply concerned about environmental issues, just as some settlers cooperated with the charitable societies and even served as friendly visitors. When the need for advanced training was recognized by charity workers as a way to increase the effectiveness of their method and to gain professional status, the COS in New York City created the first “School of Philanthropy” in 1898, which later became the New York School of Social Work, and later still, the Columbia University School of Social Work. In contrast to the schools established by settlements, many COS-sponsored schools resisted university affiliation. During the early years, the East Coast schools furnished an apprenticetype training in agencies, provided by agency personnel and supplemented by classwork, rather than a university-based education drawing upon social philosophy and social science, as in the schools founded by settlement leaders. The COS resistance to becoming involved in university education stemmed in part from the fear that an emphasis on theory would blunt the friendly visitors’ natural warmth and helpfulness. Eventually, however, all schools incorporated the apprenticeship model as the fieldwork component of graduate education. Similarly, all schools eventually became affiliated with universities, since this offered the surest avenue to professional status. Theory and practice then became blended in the graduate school, although the emphasis tended to remain more on method and less on theory and social philosophy. Settlements, Charity Organization Societies, and People of Color

At the turn of the twentieth century, African Americans were the predominant racial minority (11 percent of the total 12 percent of the nonwhite U.S. population). Native American, Chinese, and Japanese composed the remaining 1 percent. During this period of time, Mexicans were not counted separately (Iglehart & Becerra, 2000). African Americans

Black social workers operating both from the indigenous African helping traditions and from the assimilationist and scientific traditions were fully committed to mobilizing resources for black families and communities and made enormous contributions to improving the quality of life for African Americans beginning in the late 1800s (Carlton-LaNey, 1997, 1999; Martin & Martin, 1995). Unfortunately, their courage and heroism have been too often ignored in historical accounts written by white authors.

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Rural blacks migrated in record numbers from the South to Midwestern, Eastern, and Northern cities. To escape poverty and oppression, upward of a million African Americans migrated from the South (Iglehart & Becerra, 2000). Although the Civil War emancipated slaves, African Americans continued to confront the terrors of lynchings, beatings, chain gangs, and the Ku Klux Klan. Rural blacks sought employment in industry, greater freedom, and new lives in urban centers. For the uneducated, poor, and rural blacks, used to agrarian work, adapting to life in the crowded slums of large cities posed enormously complex challenges. Instead of hope and opportunity, they experienced housing, educational, and employment segregation and discrimination. The segregation they experienced in the South followed them to the North. Before long, high rates of poverty, crime, and disease occurred, “and they were soon being contemptibly dubbed by white city officials as the ‘Negro problem,’ and the primary threat to urban progress and stability” (Martin & Martin, 1995, p. 23). What did the settlements and COSs do to help African Americans? Very little, unfortunately. While a few settlement houses welcomed the influx of African Americans and a few located themselves in African American communities, most settlements refused to provide services to African Americans or simply relocated to other areas (Berman-Rossi & Miller, 1994). COSs investigated and published reports about the deplorable conditions confronting African Americans. However, their investigations and reports did not lead to any reform efforts. African Americans received significantly less alms and services than white ethnic groups received. Since racism and discrimination led to African American unemployment, the COSs conveniently concluded that their services could not be helpful to African Americans. The “friendly visitors” were not responsible for and could not mitigate discriminatory practices since their mission was to change individuals, not society. To fill the void left by settlements and COSs, as well as other white institutions, and building on the African American self-help and mutual aid traditions, African American leaders duplicated and re-created a parallel social service system for their communities. They created settlement houses, women’s clubs, hospitals, orphanages, schools, and residential centers, and established organizations like the National Association of Colored Women (NACW), the National Association for the Advancement of Colored People (NAACP), and the National Urban League (NUL). Black churches also continued to serve as a primary source of social support. In the face of profound racism and sexism, black female social workers provided the primary leadership to black communities. They mobilized the traditional informal black helping systems (churches, women’s clubs, fraternal orders,

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etc.). During the Progressive Era, for example, Victoria Earle Matthews founded the White Rose Mission, a settlement house that provided services like a mothers’ club to provide support to parents, adult classes, kindergarten, relief assistance, and a library. Matthews was also a founder of women’s clubs (along with Mary Church Terrell and Ida B. Wells) and a home for working black women. At the turn of the twentieth century, she developed travelers’ aid services as well. Mary Church Terrell, the daughter of an emancipated slave, was one of the few black women in the nineteenth century to both attend college and earn a master’s degree. Deeply affected by the lynching of a close friend whose alleged “crime” was running a successful grocery store and the death of her infant in a poorly equipped and staffed segregated hospital, she dedicated her life to social activism. She actively participated in the women’s club movement. In 1892, she cofounded the Colored Women’s League of Washington, D.C., and served as its first president. She also served as the first president of the NACW when it formed in 1896, and played an active role in the formation of the NAACP in 1910. Her autobiography, A Colored Woman in a White World, was published in 1940. Ida B. Wells (later Wells-Barnett), a crusader for human rights, fought relentlessly for the rights of black women, and she led the antilynching movement. She was a gifted journalist, referred to as the “Princess of the Press,” and wrote many articles advocating for racial justice. She equated lynching to racial terrorism—an inhuman response to whites’ fears of blacks’ political, economic, and social progress. In 1893, she organized the Ida B. Wells Club, establishing the first kindergarten for African American children in Cook County, Illinois. The club provided parental education, recreational programs, employment services, and youth and elderly services (Peeble-Wilkens & Francis, 1990). WellsBarnett’s courage and foresightedness are evident in her being the only woman in her era known to have hyphenated her given and married names. With mass migration to Midwestern, Northern, and Eastern cities, rural communities were left in a state of disorganization. Margaret Murray Washington, the final example of important contributions made by a female black woman practicing social work during the Progressive Era, organized communities on behalf of poor rural blacks, serving as the first president of the Federation of Colored Women’s Clubs. Married to Booker T. Washington, she also became a major force at the Tuskegee Institute, which he established. She founded the Tuskegee Women’s Club and joined forces with the Russell Plantation Settlement House to establish a local school and church. The Women’s Club members taught in the school, organized clubs and classes, and engaged in social service and reform activities.

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African American men who practiced social work either professionally or informally had more opportunities than their female counterparts and often were the public face of progressive developments. They identified with the emerging scientific method, advocating the training of black social work professionals rather than building on the traditional informal black helping systems. They also sought interracial alliances. Dr. George Haynes (the older brother of Birdye Haynes, who was the first African American to graduate from the Chicago School of Civics and Philanthropy), was trained at the New York School of Philanthropy. As the founder and first executive director of the NUL, he was a leading advocate for the recruitment and training of black social workers. In 1911, he played a critical role in establishing the first undergraduate social work program at Fisk University, a historically black college (Martin & Martin, 1995). In 1922, the first black graduate school of social work was established in Morehouse College and called the Atlanta University School of Social Work. E. Franklin Frazier, a leading social work educator, was also committed to the scientific method. He believed that the traditional black helping systems lacked an essential scientific knowledge base. He established in 1922, directed, and achieved accreditation for the first African American graduate school of social work, the Atlanta School of Social Work. He became even more prominent as a sociologist, becoming the first African American president of the American Sociological Association and the author of two important books, The Negro Family in the United States (1939) and The Negro in the United States (1957). Finally, Lawrence A. Oxley directed an experimental division of the North Carolina State Board of Charities and Public Welfare between 1925 and 1934. His major contributions included (1) directing a state social welfare division in a Southern state, (2) employing the first cadre of black social workers, and (3) promoting social work education and training of African Americans and support of the Bishop Tuttle Memorial Training School of Social Work at St. Augustine College in Raleigh. He also promoted and advanced community organization as a professional method and public welfare among African Americans as a viable field of practice. Native Americans

Unlike immigrant groups and African American slaves, Native Americans were not needed for inexpensive labor; the white settlers wanted their land. Native Americans fiercely fought white annexation of their land and domination over their way of life. After many tribes were massacred and their lands overtaken, Native Americans were relocated onto barren reservations. Without the ability to hunt, fish, and be self-sufficient, tribes became dependent on governmental

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support for survival necessities. They were denied the opportunity to develop their own educational and social service system by a government that allegedly provided services for them, even though those services usually were inadequate and culturally inappropriate. During the Progressive Era, so-called reformers sought to assimilate Native American children. In their view, education was the Native Americans’ pathway to Christianity and the American mainstream. Day schools on reservations were perceived to be inadequate for preparing children for what was referred to as a “civilized Christian life” (Iglehart & Becerra, 2000). Therefore, children as young as six years of age were forcibly removed from their families and entire tribes and send to boarding schools to be “civilized” and educated. The boarding schools were expected to resolve the “Indian problem” by teaching the children to shed their native ways. These schools emphasized industrial training and Christianity. By portraying Native Americans as “savages” who needed to be civilized, political leaders justified and rationalized the blatant racism and discrimination inherent in the actions of taking over their land, relocating them onto barren lands, taking their children away, and attempting to eliminate their culture. Mexican Americans

White settlers were welcomed when they moved to Texas in the early 1800s, when it was part of the state of Coahuila in Mexico. These settlers rebelled against the Mexican government, and the Republic of Texas replaced Mexican Texas in 1836. Following the Mexican-American War in 1848, thousands of Mexican Americans living in Texas and the Southwest Territory (later to become the states of California, New Mexico, Utah, and Nevada, and parts of Colorado, Arizona, and Wyoming) became citizens of the United States. In 1853, after Mexico sold the Southwest Territory to the United States, white Americans migrated to Texas and this newly opened part of the country and began to seize the Mexican Americans’ lands and exploited the people for cheap labor. Mexican Americans’ economic and social conditions further deteriorated with the influx of immigrants from Mexico after 1900. By the turn of the twentieth century, Mexican immigrants and Mexican Americans accounted for the overwhelming majority of agricultural, railroad, and mine workers in the Southwest. Mexican American workers confronted constant racism and discrimination that led to artificially low wages. For example, in Texas in 1902, white settlers instituted a poll tax that prevented Mexican American men from voting. A master-slave caste system evolved, in which Mexican Americans were relegated to serving as a cheap labor force for the white settlers and were racially segregated (Iglehart & Becerra, 2000).

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Chinese Americans

During the 1880s, almost 200,000 Chinese fled China due to political upheaval, peasant uprisings, and deteriorating economic conditions. Between 1885 and 1887, approximately 191,000 Chinese emigrated to the United States. They provided an invaluable labor supply for various industries, accepting undesirable positions at very low wages (Iglehart & Becerra, 2000). Chinese laborers’ lack of assimilation threatened dominant groups, which began to vilify them as being clannish and inferior. A wave of anti-Chinese sentiment resulted in the 1882 federal Chinese Exclusion Act, which prohibited Chinese immigrants from becoming naturalized citizens and prevented Chinese laborers from entering the United States. By the time the Progressive Era began, Chinese immigrants had gone from being viewed as essential sources of labor to pariahs. They were the victims of racism and suffered oppression similar to that of African Americans, Native Americans, and Mexican Americans. Japanese Americans

In the late 1880s, a significant number of Japanese laborers emigrated from Japan and Hawaii to work as farm laborers, domestics, and miners in California. As a result of the Chinese Exclusion Act, Japanese laborers filled the void and became a source of even cheaper labor. However, these laborers were committed to upward mobility, perceiving these jobs only as a way to enter the American economic system. They organized successful farm labor strikes and consequently achieved higher and more competitive wages. Gradually, some Japanese laborers began to purchase their own farms and businesses. Viewing the Japanese as economic competitors, the dominant white population became threatened by their successes and activated anti-Japanese rhetoric. By 1900, the anti-Japanese campaign gained momentum. The press whipped up fear and paranoia about a potential Japanese takeover of California businesses and lands. Japanese businesses were boycotted; white businesses were promoted. Legislation was also passed to curtail Japanese business success. For example, California’s 1913 Alien Land Act allowed Japanese to lease agricultural land for up to a three-year period, but disallowed additional land purchases. Moreover, Japanese children were not allowed to inherit land owned by their parents. Similarly, the federal Immigration Act of 1917 prohibited immigration from southern and eastern Asia (Iglehart & Becerra, 2000). Due to their success and business acumen, Japanese immigrants were vilified,

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excluded, and restricted. The country’s long-standing racism was glaringly evident when, after Japan invaded Pearl Harbor in World War II, many Japanese citizens were sent to internment camps.

PROFESSIONALIZATION The Casework Method

By 1895, the principles of scientific philanthropy had become organized into what was called the “casework method.” During the first two decades of the twentieth century, the method spread from the COSs (soon to be known as “family agencies”) to hospital social service departments, child-placing agencies, the school social work field, court clinics, and state mental hospitals. Paid workers, who were eager to achieve professional status, had replaced the volunteer friendly visitors. COS workers were joined in this aspiration by caseworkers in psychiatric and general hospitals, who were themselves achieving some measure of status by their collaboration with physicians. During World War I, the usefulness of the casework method for work with soldiers’ families demonstrated that it could be applied to a range of problems in family life, not just those associated with poverty. In 1915, Abraham Flexner, a physician who had recently completed an assessment of the status of the medical profession, was invited to speak at the NCCC. NCCC leaders expected Flexner to pronounce that social work was also a profession; they were shocked when he said that social work was not a bona fide profession for two major reasons. First, it lacked a defined, transmittable method; second, its liaison function between clients and other professions was not a professional function (Flexner, 1915), even though social workers were playing an increasingly important role in mediating between the dehumanizing organizational world of the late nineteenth and early twentieth centuries and advocating for the needs of distressed individuals, families, and communities. Flexner also asserted that social work did not have a unique, transmissible method, which would have qualified it as a profession. In response to his criticism, Mary Richmond’s (1917) Social Diagnosis developed a casework method. Borrowing from medicine’s “study, diagnosis, treatment” metaphor, she professionalized social work practice, but unfortunately, at the same time, she obscured the importance of the profession’s unique mediating function. The quest for a casework method was supported by the knowledge gained through the mental hygiene and child guidance movements of the 1920s, and was further advanced by the theoretical contributions from Sigmund Freud, who

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offered both a theory about human behavior and a method to help people. The Great Depression led to the transfer of relief-giving from private agencies to the newly created public ones. This provided private agencies with the opportunity to experiment with the new psychoanalytically oriented procedures, solidifying an emphasis on individual change. Beginning in the mid-1930s, a new controversy erupted within the casework segment—one that also supported the preoccupation with method. Faculty at the University of Pennsylvania School of Social Work constructed a view of casework, which was not to be treatment in the disease sense, but rather a service offered in terms of agency function (Taft, 1937). Penn faculty promoted the concept of agency function, arguing that it was this factor that defined clients’ ability to ask for and use help. The term “functional” came to be applied to this new view of casework, as distinctly different from the traditional or “diagnostic” school of casework. For more than twenty years, conflict raged between the two schools of thought. Even though the traditional view of casework predominated, many practitioners have incorporated key components of the functional school into their practice, often without realizing it. These include ideas about the working relationship, usage of time, and the influence of the agency setting on social work practice (Dore, 1990). Bertha Reynolds asserted that both schools of thought were guilty of placing social work method within a psychological orientation that led caseworkers away from social concerns and issues. In 1957, Helen Harris Perlman published Social Casework: A Problem-Solving Process, which represented an approach to casework that merged the two divergent perspectives. The pressing social issues of the 1960s and 1970s, including civil rights, the war on poverty, and the Vietnam War, further weakened the prominence of casework in the profession. In their long effort to perfect their method, caseworkers succeeded in developing an individualized service that emphasized logical thought and drew upon knowledge and values as a base for the method. They attempted to maintain openness to new ideas to develop greater effectiveness. What appeared to be missing in the casework method, however, was a conceptualization that accounted for the environment and its influence on individuals and that would lead to the development of appropriate interventions. This fact, together with the infusion of psychoanalytic theory, the tendency to model the style and trappings of practice on the psychoanalytic-psychotherapist practitioner, and the prestige associated with psychiatric casework, assured the continuation of the medical metaphor of diagnosis and treatment (Germain, 1970). The transition from an earlier psychoanalytic emphasis on drives and defenses to an emphasis in the 1950s on the adaptive functions of the ego helped

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to encourage greater interest in environmental interactions. Florence Hollis (1964, 1968, 1972) made a significant contribution by studying case records and developing a typology for intervention. Similarly, additions to the knowledge base from the social sciences in the 1950s and from general systems theory in the 1960s expanded the caseworker’s diagnostic understanding to include the dynamic environment. Specialized developments such as milieu therapy, used in residential psychiatric settings, and crisis intervention in the 1960s and 1970s also broadened practices. While each of these influences, to differing degrees, broadened the location of problems, they did little to change the focus of casework treatment because diagnosis continued to locate problems mainly within the person. Reynolds was an important exception to this obfuscation of the environment. She had been trained as a psychiatric social caseworker and practiced many years in that capacity, and she also was a noted social work educator and scholar (Reynolds 1934, 1942, 1951). But with the Great Depression and the coming of World War II, she became radicalized and committed to Marxist thought. She became dedicated to union organizing and played a significant leadership role in the union movement. She was one of only a few social work leaders who fully embraced unions, while also arguing that social work was a profession. Because of her radical views, she was ostracized by her profession and retired long before she had intended. Reynolds (1934) wrote from deeply humanistic convictions about human rights and the human potential for growth and health, as well as out of love and respect for her profession. She declared that social work could serve both client and community only if the processes of social change lead to an organization of society in which the interests of all are safeguarded through the participation of all in political and economic power, a society in which none are exploited economically and none are deprived of some form of expression of individual will (p. 126).

Reynolds also believed that exploitation could be countered by the principle of self-determination, which today we might call “self-direction” or noncoercive personal power. She shifted the responsibility for identifying and solving a client’s plight from the social worker to the client. The client has the right to decide when help is needed, what help will be useful, and when it is no longer needed. Those being served are the source of authority for their own affairs. This does not mean that the social worker has no professional input, but rather that professional input

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must be situated along the road to the client’s goals. Reynolds felt that practitioners should not find their rewards in changes they make in people—as proof of their own professional achievement—but in human beings being able to make their own conditions better. Reynolds also believed that the social worker must be willing to discuss with clients their victimization by injustice—the foreshadowing of feminist and empowerment theories. While these were radical ideas at the time, we can now see how Reynolds’s vision of casework was an influential precursor to the contemporary view of casework, which emphasizes client empowerment and strengths within a broader environmental context. The Group Work Method

During the 1920s, social group work emerged from the settlement, recreation, and progressive education movements. The group work method derived its institutional base from the settlements. Some early group work leaders had been settlement residents and were influenced by the settlers’ devotion to the idea of using democratic groups for the development of responsible citizenship, mutual aid, and collective action. From the recreational movement, social group work gained its interest in the value of play and activities. Many early group workers had been associated with youth-serving organizations, the camping movement, and community centers. Group workers assumed that organized recreation provided a means for building character. They believed that participation in leisure-time group activities led to personal development and to the acquisition of desired social attitudes and values. From the progressive education movement, group work acquired a philosophic base. One of the leading proponents of this movement, John Dewey, stressed that democratic citizenship was best ensured through democratically oriented classrooms, in which the group experience was used to help pupils learn and discover together (Dewey, 1930). To live democratically represented the most effective means for learning democracy. He presumed that creative group life in the schools could lead to responsible citizenship, on which democracy depended. The first group work curriculum in a school of social work was introduced at Western Reserve University in 1927. By the 1930s, the recreational and educational components of group work practice had been identified, and practitioners from various fields were invited into the American Association for the Study of Group Work (AASGW), founded in 1936. Until the mid-1950s, group workers maintained their commitments to the reciprocity between individual satisfaction

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and the social good, as well as to the positive impact of group experience upon both the individual and society. Coming as they did from the settlements, recreation settings, and the progressive education movement, they conceived group work functions as including the promotion of individuals’ development, the fostering of creative self-expression, the building of character, and the improvement of interpersonal skills (Coyle, 1947, 1948). Group work functions also included the cultivation of cultural and ethnic values, the teaching of democratic values, the support of active and mature participation in community life, the mobilizing of neighborhoods for social reform, and the preservation of ethical and middle-class values. This conception of group work functions has been termed the “social goals” model of group work (Papell & Rothman, 1966). The need for clarity of purpose and for the development of systematic knowledge led to the establishment of the American Association of Group Workers (AAGW) in 1946. Although group workers had initially resisted identification with any one discipline, they now began to move closer to the social work profession. In 1956, AAGW was incorporated into the National Association of Social Workers (NASW). In the process, group work gained greater professional acceptance and legitimacy. The practice committee of the group work section of the NASW assumed responsibility in 1959 for developing new working definitions of social group work practice. These discussions renewed interest in and identified critical knowledge gaps, but professional group work methods and skills remained underdeveloped. McCarthyism and the anticommunist political environment influenced the search for a unifying statement of professional function (Andrews & Reisch, 1997). An emerging view of groups as conspiratorial and subversive, rather than as microcosms of democratic society, stripped away the social goals ideology. Because a distinct method remained undeveloped, social group workers were now left without a theoretical and philosophical base. They turned inward to self-evaluation and professionalization and turned away from the social action and social reform traditions. Unable to agree on a common, precise definition of social group work’s purpose and function, the practice committee of NASW invited several group workers to offer their frames of reference. One of these individuals was Robert Vinter, who preferred the more developed casework paradigm of social study, diagnosis, and treatment. Individual group members with problems in social functioning were to be treated within the group context. The group itself possessed no collective function, and especially not one oriented toward social action. As casework agencies and casework departments became increasingly interested in group approaches, Vinter’s conceptualization of the Remedial

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Model (1966) found increased support. The transition away from group work’s historic commitment to democratic processes and social causes resulted in a model of group intervention that placed the burden of change upon the individual. The environment received little or no attention. William Schwartz shared Vinter’s commitment to the development of a professional methodology. Rather than moving toward casework’s medical metaphor, however, he proposed a systemic and generic conception of social work function. While maintaining the vision and, at times, the romanticism of the social goals model, Schwartz (1961, 1966, 1971) developed a “reciprocal” conception (also referred to as the “interactionist” and the “mutual aid” approach) of group work, in which the worker maintains a dual focus on the individual and the social system (the group, the agency, etc.). The idea of “reciprocal” captures the mutually dependent relationship that exists between members within a group and between the group and its social environment. “Interactionist” emphasizes the interaction between people and their systems. Schwartz was probably the first to introduce the term of “mutual aid” into social work scholarship and became its major proponent (Gitterman, 2006, 2017; Shulman, 1986). Both the social goals and reciprocal models viewed the group as having the potential for mutual aid. In the reciprocal model’s formulation, the worker does not have preconceived goals or a hidden agenda, but is expected to mediate between agency services and client needs. The relationship between the individual and society is viewed as symbiotic, even though the mutual need may be unrecognized. The worker’s function is to mediate between the individual and the group and between the group and the agency and the wider social environment. The symbiotic conception, however, tended to obscure the power inequities in social structures, and therefore gave insufficient attention to using groups to influence organizations, communities, and legislative processes. Despite the limitations noted here, both models made important contributions to the development of the group work method and to the increased use of group workers in various settings. In the late 1960s and 1970s, spin-offs and modifications to both models appeared. Theorists associated with the Remedial Model incorporated behavioral therapy and task-centered strategies into their practice (Garvin, 1974). Theorists associated with the Mutual Aid Model, Gitterman (1979) and Shulman (1979), elaborated and deepened Schwartz’s ideas associated with the interactionist and mutual aid concepts. Tropp (1976), whose ideas resemble an “interactionist-reciprocal–mutual aid” approach, developed a humanistic, developmental perspective on group work practice. His approach presents a clear alignment with life transitions and their associated tasks that is essential to life-modeled practice.

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The Family Method

The earliest form of family intervention in social work can be traced to the COSs and friendly visitors. Mary Richmond’s Social Diagnosis (1917) focused primarily on individual casework, but it also recognized the needs of multiproblem, disadvantaged families. Family casework was analogous to individual casework and typically took place in clients’ homes and focused on problems within the family rather than broader social forces. Social workers became disillusioned and dissatisfied with mental health services, which they viewed as repressive, too narrowly focused on the individual, and disproportionately targeting the poor and disadvantaged. In response, family intervention as a distinct method of practice within the social work profession began to emerge in the early 1950s. The evolution in thinking about family work in social work paralleled and was greatly influenced by what was generally happening in the field of mental health. In the 1950s, the slow pace of client change increasingly frustrated therapists from a range of disciplines, who were practicing from a psychoanalytic/ psychodynamic framework. These individuals also recognized that their clients’ progress was either enhanced or sabotaged by family relationships. The post– World War II era also saw a significant upsurge in the number of individuals in need of mental health services; this resulted in the increased use of family and couple interventions as a way of managing the large caseloads that agencies faced (Kaslow, 2010). The development of family therapy as a distinct method in the mental health fields also can be traced to the Child Guidance Movement, which began in Chicago in 1909 and came into greater prominence after the Judge Baker Guidance Clinic was established in Boston in 1917 (Kaslow, 2010). The model of practice employed in these clinics was for a psychiatrist to see the child while a social worker met separately with the family (often just the mother). Like their counterparts providing psychoanalytic and psychodynamic therapy to individuals, the child guidance professionals began to recognize that the child’s problems were linked to family dysfunction. The late 1950s saw increased interest in the role family functioning played in explaining mental illness, particularly schizophrenia. Some of the earliest and most influential pioneers in the field of family therapy formed the Mental Research Institute (MRI) in 1958, including Virginia Satir, Don Jackson, Gregory Bateson, and Jay Haley. Their conceptualizations regarding the nature of family dysfunction, particularly in the areas of communication and affect regulation, laid the theoretical foundation of the modality moving forward.

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This disenchantment with traditional means of treating the mentally ill coincided with a growing interest in and acceptance of systems theory. “General systems theory,” as it was originally known, had its origins in physics and the notion that the world—the cosmos—was more than the sum of its parts. In the 1920s and 1930s, Ludwig von Bertalanffy applied the systems conceptualization to the biological world and observed that no living organism existed in isolation from other living organisms (1969). He argued that all organisms were interdependent and in a constant state of influencing and being influenced by one another. The notion that organisms—including individuals—existed in reciprocal relationships held great appeal for social work professionals. Its scientific foundation was viewed as a means of promoting social work as a legitimate profession. For social workers concerned with the profession’s mission to effect social change, systems theory provided a rationale for addressing the broader social forces that affected clients. Systems theory provided social workers with a justification to move beyond an exclusive focus on intrapsychic processes as the source of clients’ mental health challenges. The logical extension of systems theory in mental health care was to attend to family factors that might contribute to, explain, or mitigate an individual’s struggles. The refinement in thinking about family intervention that was taking place in social work was influenced by the simultaneous work being done at the MRI. Since its inception as a method of practice in social work, family intervention has faced the struggle that has defined the profession as a whole: is the modality a cause or a process (Frankel & Frankel, 2006). While the early family social workers recognized the negative impact that traditional approaches to mental health treatment had on the poor and disadvantaged, this recognition generally did not translate into attention to the social environments within which families existed. In fact, several authors argued that a family focus reflected fears widely held in the 1950s that the nuclear family—and therefore, Western society and its values—were under siege (Frankel & Frankel, 2006). From this perspective, family casework represented a conservative initiative designed to promote traditional American values. Analogous to the evolution of casework and group work, family casework adopted a largely medical model of family functioning, even though its roots in systems theory provided a rationale for social action (Walsh, 2003). Family intervention in social work focused largely on intrafamilial processes until well into the 1980s. A notable exception to this orientation was the work of Salvador Minuchin (1967; 1974), a psychiatrist who addressed the needs

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of families living in poverty. His structural approach to family therapy focused on identifying the ways in which poverty and oppression undermined families’ executive functioning, which included parenting and decision-making. Because of the attention that Minuchin devoted to a client group to which the social work profession was committed, the profession was quick to embrace the structural approach (Aponte, 1974). Despite the recognition of the role that poverty played in family distress, the structural approach focused primarily on changing internal family dynamics rather than broader social forces that might affect or explain them. The Community Organization Method

Casework and family intervention originated in the COSs, and group work had its roots in settlement houses. Community organization as a practice method derived its characteristics from both the COSs and the settlements. Community organization took some of its purpose from the COS interest in pioneering new services to meet needs, coordinating existing services, and establishing central informational and statistical services for all agencies. This emphasis predominated in the decades between 1910 and 1930, when community organization sought to establish an institutional base in the developing community chests and councils. The characteristic settlement emphasis on neighborhood services also persisted in the community organizers’ interest in developing, expanding, and coordinating services. The settlement interest in social action and reform, however, was missing in the early development of community organization due to the dominant emphasis on rugged individualism within the culture. Instead of challenging institutions, the community organizer coordinated service provision among agencies and won the support of business interests in the community. Any effort to encourage citizens to band together to attack social problems was threatening to the local political structure and was quickly defeated. Although the period of the 1930s through the 1950s was characterized by the chaos of the Great Depression, World War II, and postwar recovery, community organization remained largely unchanged. The social action and social protest movements of the 1930s took place outside of community organization, which maintained its involvement in community chests and councils and in the newly developing United Funds. The period did see the beginnings of theoretical development. However, the emphases were chiefly on the adjustment between social resources and social welfare needs, intergroup processes within the councils themselves, and such generic social work features in community

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organization as problem-solving and various helping roles utilized in working with committees and council groups. The lack of a social change perspective and a focus on process instead of goals meant that the issues of power and social and economic inequality were not addressed or recognized. Modern community organization practice emerged in the 1960s and 1970s. The impact of massive poverty existing side by side with affluence, the persistence of social problems despite advances in knowledge, and the civil rights, antiwar, and women’s movements profoundly influenced the direction that community organization as a practice method took. Community organization shifted from its role and function of coordinating services to viewing social problems as the targets of intervention. The earlier preoccupation with process gave way to an emphasis on goals related to social change. Like the social goals model of group work, community organization lacked a professional knowledge base and a practice method to implement its aspirations for social change. By the early 1970s, however, new social science theories supported the shift from organizational cooperation and coordination to direct intervention targeting social institutions on behalf of disadvantaged individuals and communities. Brager and Specht (1973) published the first formulation of the theory and practice of community organization in social work in its modern form. The central concepts on which community organization is based are power, social change, and conflict. Emphasis is placed on power within social systems: its location, sources, and the levels where it appears. The degree of accessibility to power and the potential for organizing countervailing power are assessed to determine the strategies and tactics for achieving social change on behalf of the powerless. Social change can create conflict, and conflict can lead to social change. The community organizer is therefore concerned with issues of conflict management in the attempted resolution of social problems. At first, there was a tendency to rely on adversarial strategies, as though agencies were always the enemy. The development of tools for organizational assessment and the formulation of intervention procedures provided a more complex view of agencies (Brager & Holloway, 1978). External events and internal professional processes moved community organization to examine broader societal problems and to develop new curricular emphases in administration and social policy practice. Rothman (2007) formulated three approaches to community interventions: locality development, social planning, and social action. Locality development represents a neighborhood-based strategy of engaging significant stakeholders to improve community life. Social planning represents the engagement of professionals in a technical problem-solving process to improve the delivery of social service programs and

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inform social policy. Social action represents the organization and mobilization of disadvantaged communities to obtain increased resources or more equitable treatment from those in a position of power and influence. The Social Administration Method

Business leaders provided the financial resources for the COSs and aimed to transfer methods of administrative efficiency from the world of business to the societies. Board of directors (or trustees) oversaw the societies’ operations. Board chairs often held the position for many years and shared functions with the executive director by being involved in the day-to-day operations of the agency. Board committees were involved in case decisions, and board members’ wives frequently served as friendly volunteers. The board was also responsible for coordination of relief efforts among the various charity organizations. In contrast, the settlements (at least the early ones) were not dominated by board involvement. The head worker with a social reform mission provided the leadership. However, when the head worker had to be replaced, the board was responsible for finding a new one. And through the interviewing and hiring processes, boards became more involved in the administration of the settlement houses (Austin, 2000). Two distinct models of social welfare administration emerged: administration in the private nonprofit sector and administration in the public social welfare sector. In the private nonprofit sector, professional education and practice experience were considered prerequisites for administrative positions. By the 1920s, men were recruited to serve as administrators from a larger pool of professionals with social work education in casework and with experience in nonprofit organizations. These administrators sought to develop greater functional clarity between the board of directors and the executive director. An important concept of private sector administration evolved, in which the board’s function was to establish a policy and the executive’s function was to implement the policy. Mary Parker Follett’s (1941) Dynamic Administration, published posthumously, conceptualized essential structures and methods for nonprofit administration. She emphasized notions about organizational integration, staff participation in decision-making, and the sharing of power. An administration’s core function was to support and facilitate the work of social work practitioners. Administrators were viewed as serving a linkage and mediating function between the board and agency staff (Austin, 2000). During this same time frame, public welfare began to expand with a few states developing worker compensation, old age and blind pensions, mothers’

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pensions, and child welfare programs. Breckinridge’s (1927) Public Welfare Administration dealt with the administration of public welfare programs. The Great Depression fundamentally changed the role of the federal government in caring for its citizens. Through the Social Security Act of 1935, a variety of federal social welfare programs and services were established and administered by federal and state welfare organizations. Federal employees were protected from political interference by being granted civil service status. Initially, experienced workers from COS were recruited for supervisory and administrative positions. However, over time, the public welfare agencies turned to the field of public administration for the staffing and establishment of administrative procedures. Social work education and practice experience became less desirable criteria for administrative positions (Austin, 2000). Administration of public agencies emphasized accountability and standardization of practice rather than providing needed services to vulnerable clients. Graduate social work programs, mostly located in private colleges and universities, focused on preparing social workers for casework roles in private, nonprofit agencies. Growing out of a concern that social workers were not being prepared to practice in the public sector, Hollis and Taylor (1951) conducted a study recommending that social work curricula be expanded to include content on administration and supervision, as well as teaching and research (Austin, 2000). Following the publication of the report, the Council on Social Work Education (CSWE) in 1952 circulated a curriculum policy statement that mandated the inclusion of content on organizations and administrative procedures for all students, “but only schools with ‘adequate resources’ would be able to offer a practice concentration in administration” (Austin, 2000, p. 44). Subsequently, the CSWE initiated a national curriculum study that led to the recommendation that social administration should be available to students as a social work method. However, the council failed to adopt this recommendation. Instead, it conceptualized social administration as an enabling method, providing relevant knowledge for direct service workers. Schools with sufficient resources were able to offer a social administration method. Gradually, macro content and macro concentrations were added to graduate curricula, and social administration texts began to be published (Schatz, 1970). The Social Policy Method

Policy-practice is a relatively recent professional development. Through the 1970s, social welfare policy was taught as a context for individual, family, group,

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and community practice as well as social administration. In the 1980s, an increased focus on clinical social work practice, including the movement into private practice, led policy-oriented educators to search for ways to integrate social policy and social work practice. Jansson (1999) merged policy and practice by conceptualizing the method as policy-practice, which he defined as “efforts to change policies in legislative, agency, and community settings, whether by establishing new policies, improving existing ones, or defeating the policy initiatives of other people” (p. 10). This inclusive definition insufficiently differentiated policy-practice as a method specialization from policy-practice as an expansion of traditional conceptions of direct practice. Policy-practice is both a method and a specialization. It is most clearly reflected in legislative advocacy. Yet, for all social workers, policy-practice reflects the perspective that the personal is political. All social workers must recognize that clients’ problems often reflect socioeconomic and political forces and must possess the knowledge and skills necessary to address these broader challenges. Policy specialists focus specifically on policies that influence individuals, families, groups, and communities. This includes engaging in reform through litigation (such as environmental, welfare, and employment) and social policy analysis and planning. In 1989, the Social Welfare Policy and Policy Practice Group (SWPPPG) was formed to provide a national forum for social welfare policy and policy-practice faculty. SWPPG effectively raised consciousness about the need for policy to receive greater curriculum attention and space. Over time, most graduate schools developed a macro concentration in social policy and planning. For the direct practitioner, most undergraduate and graduate programs introduce students to content dealing with organizational and community influence.

LATENT CONSEQUENCES OF HISTORICAL TRENDS (1900–2019) Methodological Divisions

One consequence of social work’s historical development has been the tendency to define people’s needs or problems based upon the method of service. Because of the separate development of practice methods, agencies and workers defined themselves as “casework agencies” and “caseworkers,” “group work agencies” and “group workers,” “family agencies” and “family caseworkers,” or more recently, as “grassroots organizations” and “community organizers.”

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Such methodological divisions in social work education and practice prevented an examination of the commonalities across methods, and thus inhibited the development of a method of practice focused on the transactions between individuals, groups, families, and communities and their social and physical environments. The divisions led to past and present struggles to establish the generic or core knowledge base for all social workers and to curricular distinctions between the generalist (i.e., undergraduate) or foundation (i.e., first-year master’s) curriculum and a second-year “specialization.” The profession continues to struggle with the generic or core knowledge issue, made more complex by the differential levels of professional education, the place of in-service training after such education, and the question of where generic versus specialized knowledge can best be located in the social work curriculum. Cause and Function

Earlier in the chapter, we described the tension between those who supported environmental reform and social action (“cause”), and those who favored a focus on client change and the development of a method by which to achieve such change (“function”). Since its earliest days as a profession, casework was the dominant force in the profession because it was the method adopted by the majority of its earliest practitioners. In the ensuing chapters, we provide practice concepts and principles designed to eliminate the polarity between cause and function and social action and treatment, as well as to address the issue of social work’s fundamental purpose.

CURRENT SOCIETAL CONTEXT

The last three decades have witnessed major developments that have dramatically affected people’s lives as well as social work practice. The confluence of economic, political, and legislative forces has conspired to oppress poor families, particularly poor families of color. The shift from liberal to conservative views in the United States throughout the 1980s, 1990s, 2000s, and 2010s led to severe cutbacks in services and programs developed during the eras of the New Deal and the Great Society. Deregulation has led to wide-ranging corporate abuses and environmental degradation. Increased military spending and a corresponding and ongoing “war on terror” have resulted in decreased spending for social programs. The abuse of power in public and private life has led to an alienated and disillusioned populace. The polarization of the political parties has resulted

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in a citizenry that is deeply divided. While the human, financial, and environmental costs of these events are not yet fully understood, it is likely that for generations to come, all U.S. citizens will be burdened with higher taxes, reduced purchasing power, a shrinking social safety net, and crumbling infrastructure. The changing economic, social, and political climates have been especially hard on our most vulnerable citizens as a result of globalization, massive cuts to social programs in favor of military expenditures, and tax cuts for the wealthy. The Affordable Care Act, also known as “Obamacare,” which provides health insurance for high-risk populations, is under constant attacks and threats of repeal, particularly after the election of Donald Trump to the U.S. presidency in 2016. His anti-immigration executive orders have led to deportations, blocked asylum seekers at our borders, exposed incoming immigrants to inhumane conditions, and separated immigrant families. A politically conservative era has fundamentally changed the role of government in meeting human needs. Consequently, large sectors of our client population have experienced increased distress and deprivation, including a disappearing middle class. The misery and human suffering encountered by social workers in the twenty-first century are different in degree and kind from that encountered in the 1950s, 1960s, 1970s, 1980s, and 1990s. Social work interns and professionals daily confront the crushing impact of problems such as protracted unemployment due to robotics and the loss of manufacturing jobs; homelessness and the lack of affordable housing; high rates of opioid abuse and alcohol addiction; high rates of incarceration, particularly for people of color and the poor; hate crimes perpetrated against people of color, Muslims, immigrants, and members of the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community; family dislocation, violence, and child maltreatment; and community and gang violence (Gitterman & Sideriadis, 2014). Social workers in practice today and tomorrow will deal with profoundly vulnerable populations, overwhelmed by oppressive lives and circumstances and events over which they have no control. The problems often are intractable because they are chronic and persistent and are tied to broader structural forces that require macro interventions. When community and family supports are weak or unavailable, and when internal resources are impaired, clients are vulnerable to physical, cognitive, emotional, and social deterioration. While historically the profession of social work has assumed the task of providing social services to disadvantaged and vulnerable populations, this task has become significantly more difficult to fulfill. The persistent truth is that social problems have been increasing while resources to mitigate them have been decreasing.

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The textbook went into production in the midst of the COVID19 pandemic and soon after the killing of George Floyd at the hands of Minneapolis police officers and the resulting protests that—as of this writing—continue unabated. The pandemic has revealed in stark terms the consequences of systemic racism and deeply rooted income inequality. It is our fervent hope that social workers seize upon this moment—working alongside of the Black Lives Matter protesters—to advocate for social, economic, and racial justice. Poverty

The environment in which poor people live is particularly harsh and reinforces their oppression. They have limited access to needed resources. Because of their economic position, they are unable to command needed goods and services. Good education, preventive health care, jobs, housing, safe communities, neighborhood amenities, and geographic and social mobility are unavailable or extremely limited for the poor. They are not able to compete for societal resources, and their leverage on social institutions is extremely limited. A devastating cycle of physical, psychological, and social consequences follow. With President Trump and a Republican-controlled Senate reducing the federal government’s role in providing a safety net, the plight of the poor (particularly poor people of color, immigrants, and children) could only worsen. Poverty in the United States continues to be an intractable problem that disproportionately affects certain populations. Data from the U.S. Census Bureau’s most recent Current Population Survey (CPS) Annual Social and Economic Supplement (ASEC) indicated that real median household income (adjusted for inflation) was $61,372 in 2017. The official poverty rate was 12.3 percent. When these indicators are broken down by race, disparities become clear. In 2017, the median income for non-Hispanic white households was $68,145; for blacks, $40,258; and for Hispanics, $50,486. For non-Hispanic whites, the poverty rate was 8.7 percent; for blacks, 21.2 percent; and for Hispanics, 18.3 percent. The rate for people with disabilities was 24.9 percent. In terms of residence, the poverty rate in 2017 was 9.7 percent in suburban areas, while it was 15.6 percent in the inner city and 14.8 percent in rural areas. There are many reasons for the greater risk of poverty faced by people of color. Chief among them is the ongoing effect of institutional racism. People of color are more likely to reside in inner cities, where public school systems are routinely underfunded and student academic performance is weak. Limited job opportunities and lack of transportation also contribute to the higher rate of

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poverty for people of color in inner cities. Black males in inner cities typically do not complete high school (Proctor, Semega, & Kollar, 2016; Shaefer, Wu, & Edin, 2016). This increases their risk of unemployment. In 2000, 65 percent of black male high school dropouts in their twenties were jobless. By 2014, 72 percent were jobless, compared with 34 percent of white and 19 percent of Hispanic dropouts. When high school graduates are included, half of black men in their twenties are jobless. Concomitantly, incarceration rates of black men continue to rise (Shaefer et al., 2016). By their mid-thirties, six in ten black men who dropped out of high school have spent some time in prison, and this trend has become even more pronounced in the last ten years (Fox et al., 2015). In fact, the United States has the highest rate of incarceration of any nation in the world, and the rate of incarceration for black males is 400 percent higher than that of any other racial or ethnic group in the United States (Shaefer et al., 2016). Women are at greater risk of being poor than men. The 2017 CPS ASEC data reveal that the poverty rate among males was 11.0 percent, while for women it was 13.6 percent. Older women are particularly vulnerable. For women aged 65 and older, the poverty rate was 8.3 percent, compared to 5.0 percent for men. While the rate of poverty was 9.3 percent for all families, it was 4.9 percent for families headed by a married couple, 12.4 percent among male-headed families with no female, and 25.7 percent for female-headed families with no male. Children also are at significant risk. For children under the age of 18, 19.7 percent lived in poverty in 2017. While children represented 23.1 percent of the overall population in 2017, they accounted for 33.6 percent of those living in poverty. The “feminization of poverty” has become a growing concern, which is at least partly explained by the fact that women with children, particularly women of color, are often the sole caregivers in their families (Richards, Garland, Bumphus, & Thompson, 2010). Of growing concern is the increase in the number of individuals considered to be in “deep poverty”—those living below 50 percent or more of the poverty index (Fox et al., 2015). Data collected over more than a 40-year period, from 1968 to 2011, indicate that the number of individuals experiencing deep poverty has stayed relatively stable (Fox et al., 2015). The characteristics of those in deep poverty, however, have changed. Over this same period, the number of single parent–headed families—most of which are headed by women—in deep poverty has grown and now accounts for over 50 percent of those in this group. A significant increase also has occurred in the number of working-age families without an employed adult, working-age families with a disabled or ill member, and disabled individuals not in families. According to the most recent data available from the Census Bureau, 45.6 percent of those living in poverty meet the criteria for deep poverty.

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Income Inequality

Income inequality in the United States is as significant a social problem as poverty. While the overall rate of poverty has remained relatively stable, the gap between the highest- and lowest-income Americans has grown considerably. Until the 1970s, incomes at all levels grew steadily and at about the same rate (Stone, Trisi, Sherman, & Horton, 2016). From 1979 until the financial crisis and recession of 2007–2008, the average income for the top 1 percent of earners after taxes increased 192 percent. In contrast, the income for the lowest-income earners rose 41 percent during the same period; for middle-income earners, the increase was 46 percent. The top 0.5 percent of households accounted for most of this increase. By 2013, the top 3 percent of income earners accounted for slightly more than one-third of all earned income, while the bottom 90 percent accounted for slightly more than 50 percent of income. By 2007, income disparity was as great as it was at its peak in the 1920s, before the introduction of an income tax, and has remained steady since this time. Wealth, which includes assets like investments, is even more tightly concentrated than income, and this concentration has greatly accelerated since the 1980s (Stone et al., 2016). In 2013, the top 3 percent of the population held 54 percent of all wealth, while the bottom 90 percent accounted for just 25 percent. By 2015, the wealthiest 10 percent of Americans owned 75 percent of all assets, and the top 1 percent owned 43 percent of all wealth. By contrast, 90 percent of Americans owned just 25 percent of all wealth (Saez & Zucman, 2014). The concentration of wealth and income has tightened further as a result of the Tax Cuts and Jobs Act (TCJA) that the Republican-controlled Congress passed and President Trump signed into law in 2017. For example, the top 1 percent of earners in 2018 accounted for 22 percent of all earned income (Saez, 2020). While the full impact of this legislation cannot yet be determined, nonpartisan analysis of its impact over the next ten years suggests that households with income below $50,000 are likely to see a slight decrease in after-tax income, while those with income above $200,000 will likely see an increase. Of greater concern is the risk that the significant increase in the budget deficit created by the TCJA will be addressed through regressive cuts to social programs like Social Security and Medicare that provide financial and other assistance to the poor. Health Disparities1

Black adults suffer from higher rates of illness and death than do whites. The health disparity pattern begins at birth. According to the most recent data collected by the federal government (U.S. Department of Health and Human

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Services, 2016), in 2013, the black infant mortality rate was double that of white infants (11.1 compared to 5.06) (U.S. Department of Health and Human Services, 2016). Black adults live on average four and a half years less than whites (72 years compared to 76.5 years) (U.S. Department of Health and Human Services, 2016). Between 2011 and 2014, a higher percentage of black men suffered from hypertension (42.4 percent compared to 30.2 percent for white men). A similar pattern is evident with black and white women—44 percent compared to 28 percent (U.S. Department of Health and Human Services, 2014). Every year, from 2001 to 2010, blacks had higher rates of admission to hospitals for congestive heart failure than whites (U.S. Department of Health and Human Services, 2016). A similar pattern is evident with hospitalizations for uncontrolled diabetes; the rates were higher for blacks and Hispanics than for whites (U.S. Department of Health and Human Services, 2016). Additional significant health disparities also are apparent. In relation to new AIDS cases, in 2010 the total rate was 11.5 per 100,000 population. New AIDS cases decreased for blacks and whites from 2000 to 2010, but in 2010, blacks accounted for 47.4 percent of new AIDS cases compared to 15.5 percent for Hispanics and 4.5 percent for whites (U.S. Department of Health and Human Services, 2016). A similar pattern is evident with stage 4 breast cancer. From 2002 to 2009, the rates of advanced-stage breast cancer were higher for black women than white women (U.S. Department of Health and Human Services, 2016). Generally, the disparity between whites and blacks is evident for almost all chronic health conditions. Between 2012 and 2014, out of 10 specified chronic conditions, whites reported suffering from 3.8 conditions, as compared to blacks reporting 5.6 conditions. The pattern of racial disparity begins in childhood. During the same two-year time span, for children under age 18, white children had on average 4.4 chronic health conditions, as opposed to 7.8 chronic health conditions experienced by black children (U.S. Department of Health and Human Services, 2016). The uninsured rate for U.S. citizens had begun to decline as a result of the passage of the Affordable Care Act. However, the latest figures from the CPS ASEC (2017) indicate that it is once again on the rise. In 2016, 8.8 percent of the population reported having no health insurance. The uninsured rate was higher among those living in poverty (14.9 percent), blacks (10.5 percent), and Hispanics (16.0 percent). This is due at least in part to President Trump and his Republican allies’ attempts to dismantle the Affordable Care Act and the uncertainty in the healthcare market that has resulted (Artiga, Orgera, & Pham, 2020). It is often assumed that the poor in the United States are better off than their counterparts in other parts of the world (Krogstad & Parker, 2014). However, when key indicators of health and well-being are utilized, it becomes clear that

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those living in poverty—especially deep poverty—in the United States fare as poorly as the disadvantaged in other countries, and in some cases they do even worse (Shaefer et al., 2016). For example, the life expectancy for low-educated black males in the United States is on par with their counterparts in Rwanda. The infant mortality rate for black babies in the United States is one of the highest in the world. The risk of homicide in high-poverty cities in the United States rivals that of Rwanda, Brazil, and Trinidad and Tobago. Immigration

The United States has become a pluralistic, multicultural society. An analysis of Census Bureau data by the Center for Immigration Studies shows that the U.S. immigrant population (legal and illegal) reached a record high of 42.1 million—an increase of 1.7 million—in 2014 (Camarota & Ziegler, 2015). The authors report that the foreign-born population increased by 4.1 million from 2011 to 2015— 1.7 million in the last year alone (Camarota & Ziegler, 2015). Within a year, the immigrant population grew to 42.4 million (Camarota & Ziegler, 2016). By 2015, nearly 59 million people had emigrated to the United States, “pushing the country’s foreign-born share to a near record of 14 percent” (Pew Research Center, 2015). In 2000, the U.S. Census Bureau projected that by the year 2050, ethnic minorities will compose almost half of the U.S. population, with non-Hispanic whites decreasing from the present 75 percent to 53 percent (Iglehart & Becerra, 2000). Between 1965 and 2015, new immigrants and their descendants accounted for 55 percent of U.S. population growth. By 2015, the Pew Research Center, based on current demographic trends, projected that by 2065, immigrants and their descendants will account for 88 percent of the U.S. population increase, approximately 103 million people, as the nation grows to 441 million (Pew Research Center, 2015). For the past half-century, these modern-era immigrants and their descendants have reshaped the country’s racial and ethnic composition. While in 1965, 84 percent of the U.S. population was non-Hispanic whites, by 2015, the share of non-Hispanic whites declined to 62 percent. Concomitantly, the Hispanic percentage of the U.S. population increased from 4 percent in 1965 to 18 percent in 2015. Recent immigrants are confronting numerous stressful and traumatic life events, such as separation from family, exposure to life-threatening situations, finding employment and housing, and learning a new language and culture. Some are legal immigrants. They have the support of family and/or employment sponsorship—immigration prerequisites. Others are lawful permanent residents. They have an organizational sponsor who guarantees economic support for a

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designated time frame. Legal immigrants and lawful permanent residents tend to fare better than other immigrants. Still others are refugees, who are also legal immigrants. Refugees are different from asylum seekers, who claim this status after already being in the United States. Refugees are usually forced to leave their home countries out of fear of persecution. They have witnessed and/or directly suffered from violence, genocide, and wars. Yet others are undocumented people, who are unauthorized to be in the United States. They either are entering the country illegally or remain after their visas have expired (Drachman, 2014). With the inflammatory rhetoric of Trump about building a wall to protect U.S. citizens from an increasing number of illegal Mexican “criminals” (his derogatory term, among others) from crossing the border and his so-called ban on Muslims, social work students and professionals must be familiar with certain significant facts. First, from 2009 to 2014, the total of unauthorized immigrants has remained unchanged, accounting for only 3.5 percent of the U.S. population (Krogstad, Passel, & Cohn, 2016). Second, in recent years, the number of unauthorized immigrants in the United States, after decades of rapid growth, has stabilized and begun to decrease. The number of unauthorized immigrants, as well as those seeking asylum from Mexico, has declined, while the number coming from other nations—particularly those in Central America and Africa—has steadily risen (Krogstad et al., 2016; Zong, Batalova, & Burrows, 2019). Finally, unauthorized immigrants represent a stable U.S. population. In 2014, about twothirds of unauthorized immigrants lived in the United States for at least a decade, compared to 41 percent in 2005 (Krogstad et al., 2016). In an executive order in 2017, Trump provided Christians and others from minority religions preference over Muslims who were seeking asylum or refuge in the United States. In relation to the president’s anti-Muslim rhetoric, the reality is that two countries, Syria (12,486) and Somalia (9,012), were the source of more than half of Muslim refugees in 2016. Since 2002, a larger total number of Christians than Muslims were granted refugee status. During the past fifteen years, almost 400,000 Arab Christians were granted refugee status, compared to approximately 279,000 Arab Muslims (Connor, 2016). As with the poor, “unworthy” refugees are being distinguished from “worthy” ones and found wanting. Global Economy

Working-class and lower-income families in the United States have been negatively affected by broad changes in the global economy. Beginning in the 1970s, nations like Mexico attracted outside capital and labor by establishing free trade zones. These free trade zones permitted transnational corporations to operate

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with few restrictions related to the minimum wage, working hours, and the use of child labor. By the 1990s and early 2000s, the dismantling of trade barriers and erosion of labor standards resulted in a “massive movement of jobs” from factories in the United States in the direction of sweatshops located in southern and Asian nations (Polack, 2004, p. 285). Consequently, jobs in the United States requiring minimal skills have significantly declined, and wages for blue collar and lower-income workers have eroded. Manufacturing plants have closed, and service jobs have been outsourced. The result has been significant job losses. The job losses in manufacturing and retail have disproportionately affected young men and women of color. Despite improved employment rates and other signs of an improved economy, for many Americans, their take-home pay has consistently fallen since the economic recovery began in 2009 (Schwartz, 2015). The declines have been greatest for the lowest-paid workers. Blue collar and low-income workers, possessing less education and less technological skills, are unable to compete in an increasingly information- and technologically driven economy (Schwartz, 2015). The lowest-paying jobs have disproportionately experienced greater wage declines. Between 2009 and 2014, wage losses across all jobs averaged 4 percent. However, for those in the bottom earning quartile, those losses averaged 5.7 percent (McKenna & Tung, 2015). A downward trend also has been evident in the availability of midlevel-skill jobs, and this appears to be largely due to automation. Unlike earlier economic downturns, middle-skill jobs were not recovered after the economy rebounded from the recession of 2008–2009 (Cheremukhin, 2014). Shrinking union membership is yet another factor contributing to decreasing wages. The U.S. Bureau of Labor Statistics (2019b) reported that in 1983—the first year that comparable union data were collected—the rate of union membership was 20.1 percent and included approximately 17.7 million union workers; by 2017, the rate was 10.6 percent, or 14.7 million workers. Terrorism

A new reality of the twenty-first century is the rise in terrorism and terrorist attacks around the world. Terrorists have struck in Nigeria, Iran, Russia, Iraq, Lebanon, Syria, Saudi Arabia, Spain, the Congo, Israel, Palestine, Yemen, France, England, Columbia, Philippines, Sri Lanka, and the United States. Citizens around the world feel unsafe, insecure, and distressed. Terrorism and the threat of future terrorism have traumatized citizens in all corners of the world (Berthold & Akinsulure-Smith, 2014).

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In the United States, the terrorist attacks of September 11, 2001—in which nearly 3,000 people perished—were a turning point in the nation’s experience with terrorism and views about safety and security. The 9/11 attacks had two especially far-reaching effects. First, Americans’ civil liberties—most notably the right to privacy—were compromised due to enhanced security measures that allow the government great latitude in surveilling its citizens. Second, in the immediate aftermath of the attacks, there was worldwide support for the United States and universal condemnation of the terrorists. However, the U.S.-led wars that followed and the use of torture and indefinite incarceration for suspected terrorists significantly undermined our standing in the world and contributed to the rise of extremist Muslim groups like the Islamic State (ISIS). There actually has been a decline in the number of terrorist attacks worldwide (Harris, 2018). From a high of 14,400 in 2007, the number of attacks in 2017 was down to 8,500, the second-lowest in the last 10 years. More than 70 percent of the deaths that resulted from the attacks occurred in just five countries—Afghanistan, Iraq, Nigeria, Somalia, and Syria. While ISIS continues to be the primary group responsible for terrorist attacks worldwide, it carried out 23 percent fewer attacks in 2017 than it did in 2016. Despite the fact that U.S. citizens are far less likely to be victims of an attack perpetrated by Muslim extremists than one by citizens of other countries, the Trump administration has engaged in a continuous barrage of anti-Muslim rhetoric. Early in his presidency, Trump signed an executive order to ban people from entering the United States from seven Muslim countries. In response, the attorneys general of several states argued in U.S. Courts of Appeals that the order was discriminatory, and therefore unconstitutional. To bolster his executive order, President Trump attempted to redefine it as a travel ban rather than a Muslim ban. His public statements undercut his legal arguments, and the courts voided the ban. However, in 2019, the Supreme Court upheld at least part of the ban. Meanwhile, “domestic terrorism,” which is defined as citizens perpetrating attacks on their fellow citizens, has been on the rise in the United States, particularly since the election of Donald Trump in 2016, and it poses a much greater threat to citizens than terrorism by Muslim extremists (Clark, 2019). In almost all cases, the perpetrators are members of white supremacist groups. In 2018, for the first time, the Federal Bureau of Investigation (FBI) investigated the same number of domestic terrorism incidents as it did international ones (Clark, 2019). In the majority of cases of actual or planned attacks, white nationalists who targeted persons of color and those of the Jewish and Muslim faiths were responsible. In other instances, individuals—almost always white males—acted

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alone, often without a clear motivation or agenda. It is noteworthy that while acts of violence committed by white U.S. citizens mirror those committed by non-U.S. citizens (who are usually people of color), the American public, and even law enforcement and the government, have been reluctant to label the former as terrorism (Berkebile, 2017). Role of the Federal Government and the Social Safety Net

Since the 1980s, the federal government in the United States has taken a decreased role in addressing economic disparity, poverty, and the needs of those who are disadvantaged as a result. The lack of commitment to the concept of a “safety net” represents a significant structural failure at the political level. Cutbacks in Medicaid and public assistance result in those living in poverty not having their basic human needs met. For example, they often have to choose whether to purchase food or essential medications. The high cost of housing and utilities for those who do not qualify for assistance leaves little left over for basic necessities. With few financial resources to fall back on, these individuals are particularly vulnerable to homelessness. The United States provides far fewer resources to support the poor than do other Western industrialized nations. In 2010, governmental programs in the United States reduced the poverty rate by only 9.7 percent (Gould & Wething, 2014). When compared to 21 peer nations, government transfers in the United States did the least to reduce the poverty rate. Among all 22 nations, the average reduction in poverty rate, after government transfers, was 17 percent. The greatest reduction in poverty after governmental income transfer programs occurred in France (25.4 percent), Germany (23.6 percent), and Finland (22.1 percent). Data collected by the National Bureau of Economic Research suggest that while the federal benefit system does lower the poverty rate—by as much as half in some years—the reduction is not evenly distributed across groups (Ben-Shalom, Moffitt, & Scholz, 2011). The poverty rate declines the most for the aged and disabled, and the least for the lowest-wage earners and those with no income. For the twenty-year period in question (1985–2004), the greatest reduction in the poverty rate for single-parent families occurred early. This coincided with increases in federal expenditures for programs like the Earned Income Tax Credit (EITC), which benefited the higher-income working poor, and a decrease in spending for programs like Temporary Assistance to Needy Families (TANF), which benefited the nonworking poor. Research also indicates that government transfers have minimal impact on the rate of deep poverty, particularly for families with children. In some years, this rate actually has

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increased, even when government assistance is considered (Stone et al., 2016). Ben-Shalom and his colleagues conclude that “the U.S. benefit system is paternalistic and tilted toward the support of the employed and toward groups with special needs and perceived deservingness” (2011, p. 1). Legislation

In 1996, President Bill Clinton signed into law the “welfare reform” act—the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA). Since the creation of a federal entitlement program called Aid to Families and Dependent Children (AFDC) as part of the Social Security Act in 1935, poor families had been provided with a safety net of financial assistance. In July 1997, AFDC was replaced with TANF. This federal law imposed work requirements and a 60-month lifetime time limit on recipients, promising to “end welfare as we know it,” in the president’s words. The law requires involvement in a work-related activity, as defined by each state, within twenty-four months of receiving assistance. Recipients risk losing their benefits if they do not participate in job training or seek employment. The new law’s manifest purpose was to end recipients’ dependence on the government and create economic independence and self-reliance. However, social welfare policy experts assert that the legislation’s latent purpose was to punish poor women for having children they shouldn’t have had (Hansen, Bourgois, & Drucker, 2014; Sherman, 2013). Supporters of the new legislation ignored the fact that approximately two-thirds of the recipients receiving AFDC were children and only the rest were adults. This figure has remained consistent over time; in any given year, approximately two-thirds of TANF recipients are children (Falk, 2016). The legislation did not differentiate between a recipient’s need for shortversus long-term public assistance. The consequence of this has been that black and Latina mothers with children are at much greater risk than white mothers of reaching the time limits because of the greater difficulty they encounter finding employment (Falk, 2016). The number of people receiving TANF has declined since 1995. However, white recipients leave the welfare system at a disproportionately faster rate than black and Latina recipients (Downing, 2011). Further, Hispanic children now account for the largest portion of TANF recipients, followed by black children and non-Hispanic Caucasian children (Falk, 2016). This is accounted for by the significant growth of the Hispanic population within the United States generally. The 1996 legislation also made lawful immigrants ineligible to receive TANF, Supplemental Security Income (SSI), a program for disabled and aged

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individuals, and food stamps. Certain exceptions were made for refugees from specific countries. In that same year, the Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) was enacted into law. This legislation disqualified illegal immigrants from all public benefits and set up significant obstacles to family reunification. Similarly, undocumented immigrants were ruled ineligible for state and local programs. Moreover, persons without valid travel documents faced immediate deportation (Drachman and Ryan, 2001). With the terrorist attacks of September 11, 2001, even more repressive legislation was enacted. The Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism Act (mostly known as the USA PATRIOT Act, or just the Patriot Act) provided the U.S. Justice Department with broad powers for the surveillance and detention of immigrants. Immigrants no longer had the right to review evidence or to have legal counsel in their cases (Drachman and Paulino, 2004). The Role of Faith-Based Services

The PRWORA contained a “charitable choice” clause, which encouraged states to involve faith-based and community organizations in providing federally funded welfare services. President George W. Bush extended this policy shift as part of the faith-based policy initiatives of his administration. While some viewed this development as increasing the access of poor people to needed social services, others saw it as opening the door for mixing religion and public services, and as a significant threat to the separation of church and state. Still other social welfare experts viewed this policy direction as reducing funding for public and private nonprofit service providers, and therefore eroding the quality of the public social welfare system. Since FBS relies heavily on volunteers rather than professionals, concern was expressed that this policy direction would diminish the professional status of social work, as well as the quality of services that recipients would receive. More than twenty years after this initiative was signed into law, these issues remain problematic, but advantages also have been identified. In the face of natural and human-made disasters, FBS has provided much-needed concrete assistance, such as housing and essential items like food, water, and clothing (Alawiyah, Bell, Pyles, & Runnels, 2011). As government assistance for disadvantaged and vulnerable populations has decreased, faith-based organizations often have stepped in to fill the void (Cnaan & Newman, 2010). With the recent push to deport individuals in the United States illegally, some religious organizations have been at the forefront of protecting and advocating for these individuals

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(Snyder, Bell, & Busch-Armendariz, 2015). Research findings also suggest that FBS can provide spiritual support and guidance in a way that public and private secular organizations cannot (Vanderwoerd, 2008). Social welfare policy experts and social work practitioners continue to express concerns about an increased reliance on FBS. While spiritual assistance can be beneficial to some individuals, for others it is of little practical help. The values and beliefs of some FBS may discriminate against or disparage the needs of some groups of individuals and promote victim blaming (Vanderwoerd, 2008). FBS has been slower to respond to calls for accountability than secular organizations, and in some instances has been unable to clearly articulate the nature of the services provided (Zanis & Cnaan, 2006). A lack of coordination between conventional and FBS also has been observed in some communities, resulting in duplication of and gaps in services (Bielfeld & Cleveland, 2013). Finally, members of the faith community have expressed concern about the watering down of their religious beliefs as a condition of receiving public funds (Vanderwoerd, 2008). Technological Revolution

Technology has grown so fast and become so complex that it merits a separate discussion. In many ways, it has enriched and extended human life, beginning with the first tools used by early hominoids and extending to household aids, entertainment, scientific investigation of the largest and smallest known natural phenomena, and medical discoveries that have resulted in less invasive, computer-assisted surgical procedures and the development of new ways of treating chronic and previously life-threatening conditions such as AIDS. The most profound changes have occurred in the way that we communicate with one another. In an instant, we now can reach literally thousands of individuals through social media sites like Facebook, Instagram, and Twitter. Despite the benefits that derive from technological advances, problems abound. For example, medical technology has created means of reducing the impairment of some chronic and genetic diseases. However, persons in terminal and vegetative states whose lives would have ended in natural death are now kept alive by machines. The moral and ethical issues raised by such advances are twofold. One is the quality-of-life issue, made even more complex by legal implications when the courts take over decision-making from families and their physicians. The second is the use of costly resources for such purposes when others, particularly those who are poor, are deprived of routine healthcare or treatment of serious but remediable conditions.

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Two aspects of technology have the potential to benefit our clients, but they also present challenges to social workers. First, the availability of online resources can complement traditional services found in the “bricks-and-mortar” world. However, disadvantaged clients often lack access to the Internet, despite efforts to reduce the so-called digital divide. Thus, online resources, which are often free to all, are unavailable to individuals who may need them the most. Certain client populations, such as the aged and the illiterate, could benefit greatly from online resources but may be unable to access them due to difficulties with reading and/or navigating the web. The legitimacy of online resources can be an issue. Well-known groups like Alcoholics Anonymous (AA), Gamblers Anonymous, and Narcotics Anonymous (NA) may sponsor online sites. Online support networks also have emerged informally for individuals struggling with a range of problems from mood disorders, separation and divorce, weight management, losing a loved one, and living with cancer. These networks often lack formal backing from a legitimate, known organization or agency, which calls into question their helpfulness. A coauthor of this book, who works with adult survivors of childhood trauma, frequently directs clients to online support groups and sources of information to help them understand what happened to them and the challenges they face. This normalizes and validates their feelings and experiences. However, one client searched for an online support group for survivors of sexual assault on her own and ended up on a pornographic site, which was deeply distressing given her history of rape. The social worker should search out and review potential online resources before directing clients to them. Second, online counseling emerged in the late 1980s and 1990s and has become a more acceptable—though still controversial—form of social work practice (Reamer, 2013b). E-therapy includes online video conferencing using tools like Skype, chatting in real (synchronous) time, and communicating via e-mail (asynchronous) exchanges (Mattison, 2012). Advantages include the ability for clients to access professional help who might otherwise not be able to do so due to health or other medical or practical barriers. Clients living in more remote locations also benefit greatly from professional help online that they might not otherwise be able to access (Reamer, 2013b). One drawback to the provision of online services is associated with the issues surrounding creating a working alliance with clients in cyberspace, which can be difficult (Mishna, Bogo, & Sawyer, 2015). Recent data breaches at many public and private organizations have exposed millions of individuals to identity theft and the disclosure of personal information underscore the challenges associated with maintaining privacy in a digital world. With respect to the social work profession, we must consider who has access to our information. Clients, current and future employers, and colleagues

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all may be able to retrieve personal information—including information that might be embarrassing—about social workers (Reamer, 2015). In the case of clients, the risk of dual relationships—in which the lines between a personal and professional relationship become blurred—is heightened. Social workers also can access their clients’ information via social media, which increases the risk of blurred boundaries and raises questions about confidentiality. “The uninvited discovery of personal information on both sides of a  .  .  . relationship can have a devastating impact on the goals that have been established and could have a negative impact on the treatment outcomes” (Harbeck-Voshel & Wesala, 2015, pp. 70–71). In chapter 3, we discuss the ethical guidelines associated with technology in more detail. An increasingly important role of technology is its use in grassroots and advocacy efforts (Sitter & Curnew, 2016). Numerous websites representing both conservative and liberal viewpoints provide social workers with information and resources and a means through which they can engage in social actions. Online petitions provide an easy way for individuals to give their support to and voice their opinions about social issues of concern to them. Facebook and other social media sites provide a forum for expressing political viewpoints and sharing information about protests, marches, and other forms of social action. For instance, the Women’s March immediately following the inauguration of President Donald Trump in 2017 began as a Facebook post and ended up being one of the largest protest marches the United States has ever seen. Letter-writing campaigns have been replaced by e-mail campaigns, while social action websites allow users to contact their members of Congress with one click. We return to the use of technology in political advocacy in chapter 16. One of the more challenging consequences of the technological revolution and the immense popularity of social media is the rise in “fake news.” It is incumbent upon all social workers to carefully evaluate the sources of information they rely upon to guide their practice (and inform them in their personal lives).

CURRENT PRACTICE CONTEXT

We end this chapter with a discussion of contemporary social work practice in light of four influential developments. Using Research to Guide Practice

One of the most important developments in social work practice and education is the emphasis on using research to guide practice. This has been necessitated by

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the demands of third-party payers that we document not only what we are doing but also whether it results in measurable change. It also reflects our ethical obligations to our clients. On the surface, this may seem straightforward. However, clients’ lives are messy and complex, and there are numerous factors—many of which are not under their or our control—that can influence the outcomes of our professional efforts. We return to the implications of evidence-guided practice for social workers in chapter 5. Within our profession, there has been an ongoing debate about whether what we do is science or art. The pendulum has swung back and forth, and the current tilt is toward scientific explanations and formulations (Gambrill, 1999, 2006; Proctor, 2004). Evidence-based practice is the most widely used term to describe the social work profession’s commitment to utilizing research to inform practice. The term and the ideas behind it come from the field of medicine (Gitterman & Knight, 2013). Evidence-based social work practice has been defined as the “mindful and systematic identification, analysis, evaluation, and synthesis of evidence of practice effectiveness, as a primary part of an integrative and collaborative process concerning the selection of application of service to members of target client groups” (Cournoyer, 2004, p. 4). This perspective on the role of research in social work assumes that practitioners are aware of and able to critically review available research findings to determine an appropriate intervention strategy for each client situation. While this sounds good in theory, our practice is far from linear. Clients’ lives are complicated, and a myriad of factors come into play that may explain practice outcomes in our work. Therefore, we propose an alternative framework for social work practice—an approach that integrates rather than separates art and science, and accounts for its complexities. Life-modeled practice relies upon research findings, consistent with traditional views of evidence-based practice. Our approach, however, also requires that workers rely upon theoretical constructs and a repertoire of professional competencies and skills, consistent with the profession’s values and ethics that respond to clients’ unique situation. And our approach recognizes the role that the individual social worker’s distinctive style plays in professional social work practice (Gitterman & Knight, 2013). Evidence-guided practice is responsive to the difficulties that our profession has experienced in conceptualizing and monitoring helping interventions. The connections among theory, research, and practice are complex and mutually dependent. Theory and research findings provide practice guidelines and general direction. Rarely does the social worker’s knowledge base provide a clear-cut prescription for action. We cannot assume a linear relationship between “knowing”

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and “doing” and mechanically apply a concept or a research finding. An important distinction exists between knowing “that” (having facts and information) and knowing “how” (using facts and information). Knowledge is essential but not sufficient. The professional needs to learn how to use knowledge and how to turn understanding into taking skillful professional action. Social work is both science and art. The artistry of social work is being able to use the knowledge that we have gained from theory and research and from our clients’ personal stories in a way that responds to our clients’ unique challenges and our unique personality and style. To be a competent professional, we use knowledge, but we also use ourselves, which requires us to monitor and understand our reactions to our clients, their challenges, and their perspectives. We may work with the same type of client group or population, but each client is unique, as are our interactions with him or her. For example, Ricardo, a 27-year-old Puerto Rican social worker, is employed in an outpatient substance abuse treatment program. All of his clients are substance abusers, but there are wide variations in their histories, drugs of choice, and social identities (i.e., gender, race and ethnicity, age, and sexual orientation). Further, Ricardo’s interactions with each client are unique, based upon their shared or different identities and how each experiences the other. He has an obligation to use research to guide his practice. But his practice decisions must accommodate the distinctiveness of each client and the relationship he has with each one. In our view, professional methods cannot be confined to the mechanical use of skills. Evidence-based practice proposes that specific interventions exist to solve most types of life problems, and social workers should, through computer searches and reviewing relevant research, find and then replicate the most effective—the “best”—intervention. Logical, orderly, and sequential formulations can and do provide guidance. However, when the worker implements a strategy in an unquestioning way, without regard for the specific client and the specific circumstances and context, this is likely to be unproductive and frustrating for both client and social worker. The more traditional view of research-informed practice also fails to account for how the worker’s unique style and personality plays into and affects her or his use of skills and intervention strategies. We also believe that effectiveness of interventions cannot be evaluated solely based upon client outcomes. It is much too simplistic to assume that clients’ progress (or lack thereof) is solely the result of the workers’ skill (or lack thereof). This view ignores the complexities of clients’ lives and the power of oppressive environments and limited resources to restrict their opportunities, motivation, and willingness to change. A worker may be skillful, and yet the client may not progress, or may even regress. Similarly, the worker’s behavior may

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be unskillful, and yet client growth may occur. We must distinguish the behavior of helping from the behavior of using help. Outcomes are more easily evaluated in aggregate terms. A specific intervention may lead to positive outcomes for different clients, at different times, and in different contexts; therefore, we can have confidence that it is effective, generally. However, we cannot know whether it will work with our specific client. To credit or blame a worker for her or his clients’ progress or lack of progress dismisses the critical influences of environmental supports and gaps, as well as client strengths and limitations and the timing of the interventions in relation to clients’ and their environments’ readiness to and opportunities for change. Let us return to Ricardo and his work with substance abusers. Two of his clients have very similar histories: • Both began abusing alcohol in early adolescence. • Both progressed to abusing prescription opioids. • Both have been serially unemployed due to their addiction. • Both are recently separated from their spouses due to their addiction. • Both have sought assistance for the first time from Ricardo’s agency because they have “bottomed out” and are desperate.

A simple interpretation of research-informed practice would suggest that Ricardo acquaint himself with intervention strategies that have been found to be effective with these clients’ specific circumstances. It is unlikely, however, that research findings will address all of these variables combined. Further, the first client is Maya, a 45-year-old white lesbian, while the second is Mark, a 50-year-old African American, heterosexual man. Their and Ricardo’s social identities, coupled with his personal style, will affect their work together in ways that cannot be easily explained by research findings. Ricardo will need to, at minimum, be familiar with research on the process of addiction and addiction recovery; differences in patterns of addiction and addiction recovery for men and women and for heterosexual and LGBTQ individuals; strategies to promote engagement with substance abusers seeking help for the first time (since it is likely that their motivation and commitment to change might be weak); and strategies to engage clients who are culturally different from the worker. These findings will guide Ricardo in his work, but they cannot unequivocally direct it. Luckily, numerous resources are available to social workers to assist them with using research to inform their practice. In addition to the more traditional use of peer-reviewed articles and academic books, social workers can access

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online clearinghouses developed and maintained by social work educators and researchers, which provide summaries of and links to research on almost any topic. These include Columbia University’s Evidence-Based Practice and Policy Online Resource Training Center (http://www.columbia.edu/cu/musher/Website /Website/index.htm); New York University School of Social Work’s Information for Practice (http://ifp.nyu.edu/); and the Campbell Collaboration (https://www .campbellcollaboration.org/). In addition, many federal agencies and nonprofit organizations provide links to research studies, including the Substance Abuse and Mental Health Services Administration (http://www.nrepp.samhsa.gov/landing.aspx); the National Child Traumatic Stress Network (http://www.nctsn.org/resources/topics/treatments -that-work/promising-practices); Mental Health Research News from Science Daily (https://www.sciencedaily.com/news/health_medicine/mental_health/); and the Administration for Children and Families, a division of the U.S. Department of Health and Human Services (https://www.childwelfare.gov/topics/system wide/youth/outcomes/research/). Licensing

The 1970s saw the introduction of social work licensing, an important step in the establishment of social work as a profession. By 1992, all fifty states and the District of Columbia required social workers to hold a license. Requirements vary by state, but in all states, graduation from a CSWE-accredited Master of Social Work (MSW) program is required; this also is true for most of those states that license bachelor’s-level social workers. The Association of Social Work Boards (ASWB) is the organization that is responsible for creating the licensing exams. Individual states establish their own requirements, such as titles of licenses based upon education and years of experience, permissible professional activities for each level, supervision requirements needed to advance from one level to another, and continuing education. The requirements for each state may be found at http://www.socialworklicensure.org/articles/social-work-license -requirements.html#states. While specific requirements vary by state, it is illegal for individuals to call themselves social workers or be hired into a social work position without a license to practice. Licensing regulations also include ethical and legal mandates. Violation of these requirements can result in censure, suspension, or termination of the individual’s license. Social workers are responsible for being fully informed about the licensing requirements for their specific states.

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Agency-Based Practice

Most social workers are employed in agency-based settings (U.S. Bureau of Labor Statistics, 2019a). Agency-based practice presents numerous challenges to social workers. All organizations—regardless of their formal mission and goals or their status as public, private, for-profit, or nonprofit—have one overriding objective, which is survival. But organizational self-interest often conflicts with what is in the client’s best interest. Examples abound in which social workers are placed in a position of having to balance the needs of their clients against the demands of their employer. Consider the following scenarios: A medical social worker must discharge a patient from the hospital at the end of the day after major abdominal surgery. Insurance will not cover another night, and the hospital does not want to be responsible for covering the cost. The patient reports that she remains in intense pain and still requires a morphine drip, something that could not accompany her if she were to return home. The patient has not yet lined up the assistance that she will need from family and friends. The social worker believes that the patient needs at least one more night in the hospital. After numerous staff complaints in a residential treatment facility, the 10-yearold client’s treatment team decided to put him on large doses of sedating medication, despite the protests of his social worker. She believes that this decision was made for the convenience of the staff rather than because her client needs the medication. A rape crisis center has a ten-session limit as a way of containing costs and making services available to a larger number of potential clients. The social worker has been seeing her client for eight sessions and believes that her client is just beginning to make progress. Termination after only two more sessions would be harmful to the client. The worker also believes that the client is unlikely to continue her treatment when the ten sessions are up at her agency.

In each of these cases, the worker must develop a plan that meets the needs of the client and the requirements of the organization. At times, social workers may decide to challenge the employing organization and advocate for a change that benefits clients. We discuss the social worker’s role in influencing the employing organization in chapter 15. Public agencies are accountable to their sources of funding. Social workers—who are more likely to be employed in the public sector than in any other setting—are put in the difficult position of having to choose between the

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interests of their clients and public demands for accountability, as the following example illustrates: The public defender’s office employs a social worker. She is responsible for completing extensive social histories on clients and developing, when appropriate, a description of mitigating circumstances that a judge and/or a jury could consider when rendering a verdict. Her client is charged in the murder of a popular local DJ. The murder has been widely covered in the media, provoking much anger and outrage. The social worker believes that her client, a 28-year-old impoverished black man, is intellectually disabled and suffered from mental illness. She also has learned that the client has a long history of physical and sexual abuse as a child. She believes that each of these factors mitigates the client’s criminal responsibility for the murder. However, the director of the office—an attorney—downplays this information in response to public outcry. The director is concerned about future loss of funds due to a public perception of the agency being “soft” on criminals.

Many social workers are employed in “host” settings, such as public defender’s offices and in hospitals. The decision-makers come from disciplines other than social work and they often lack an understanding of and appreciation for what social workers do. This exacerbates the constraints that the organization places upon the social worker. Even in traditional social service agencies, administrators may not be social workers; they often come from business, management, legal, or public health backgrounds. They may possess the skills necessary to run an agency but lack an understanding of the agency’s core mission and the roles, responsibilities, and ethical mandates of the social work staff. Third-Party Payment

Social workers have become the largest providers of behavioral and mental health services in the United States, surpassing both psychiatrists and clinical psychologists (Heisler, 2018). Clients’ private insurance or public insurance programs such as Medicaid and Medicare Part B typically pay for their services. The term “third-party payment” refers to the reimbursement that providers receive from insurance companies for individuals who have health insurance. Ideally, social workers’ decisions reflect their clients’ needs, desires, and intentions. But who pays for our services significantly affects the nature and duration of the services that can be provided. Social workers are accountable not only to the client but also to the source of payment for their services.

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The Health Maintenance Organization Act, passed by Congress in 1973, ushered in a new approach to insurance coverage that placed emphasis on containing costs and requiring providers of services—including social workers—to provide documentation of their effectiveness and a rationale for their services. Third-party payment from a managed-care orientation creates two major challenges for social workers. First, confidentiality and the client’s right to privacy are compromised by the information that insurers require in order for them to authorize payment. The more information that the social worker provides about the client, the more compelling is the case for providing services. Typically, the insurance company authorizes a certain number of contacts between the client and the social worker. Should the worker and client believe that more contacts are needed, the insurance company is likely to require even more information to explain the extension. Social workers also are faced with the challenge of transmitting information—almost always electronically—in a way that maintains clients’ privacy. A second concern reflects the way in which managed care shapes the very nature of social work practice. First, our profession operates from an ecological orientation. Social workers attend to the range of factors in the client’s immediate and wider sociocultural and economic environments that contribute to and explain her or his difficulties. Yet insurance reimbursement depends on an agreed-upon system of diagnosis and classification. The most common is the American Psychiatric Association’s Diagnostic and Statistical Manual for Mental Disorders, fifth edition (DSM V) (APA, 2015). Diagnostic classifications ignore or greatly oversimplify the complex interplay of factors that contribute to and explain client difficulties. Second, because managed care values cost containment, brief, goal-oriented intervention approaches that focus on acute symptom relief are preferred. The emphasis on short-term symptom reduction can neglect the underlying life stressors that often create the symptoms that clients experience. “Quick-fix” relief of symptoms does not readily ameliorate the intractable and overwhelming life stressors associated with poverty, oppression, and discrimination. Third, the independence and autonomy of the social worker–client relationship is weakened because of the managed-care oversight function. Social workers traditionally collect relevant information so that they—in partnership with their clients—can determine how to be helpful. In contrast, insurers collect information to determine the legitimacy of the client’s request for coverage. Social workers experience tremendous pressure to adhere to time limits imposed by third-party payers rather than to work with clients to decide upon a mutually agreed-upon time frame.

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Fourth, the social work profession places great weight on the empowerment of clients. Our job is to help clients help themselves and enhance their capacity to better navigate their social environment in the future. The mandates of thirdparty payers undermine this goal since decisions about intervention lie partly in the hands of insurance companies. These challenges require social workers to think creatively about their practice. “Partnering” with managed-care and third-party payers has become one way of balancing the demands of insurance providers and the needs of clients. Social workers and their clients are not totally at the mercy of insurance companies. A defining feature of social work practice is advocacy. We discuss this in depth in later chapters. But in the context of insurance reimbursement, partnering means that social workers advocate for their and their clients’ interests and teach clients to become self-advocates. The practitioner and client work with, not for, the insurance provider. This promotes client empowerment, even in a context that at first glance seems oppressive and controlling.

CONCLUSION

In this chapter, we have traced the development of the social work profession. Relative to other professions like medicine and law, ours is still young. We continue to grow and evolve in the face of an ever-changing landscape. We identified major occurrences that contributed to the development of the profession. We also have identified what we believe are the realities of contemporary social work practice. Social work students may view current and future challenges as overwhelming. However, the model of practice that we present in the remaining chapters in this book provides readers with the methods and skills necessary to negotiate the many challenges they face while still maintaining their ethical obligations to clients and their enthusiasm for and commitment to the profession.

The Ecological Perspective

TWO

The ecological perspective emphasizes the interdependence of all living organisms and their environment. It is an especially suitable metaphor for social work, given our historic commitment to the person-and-environment concept. The ecological metaphor represents and reinforces the profession’s commitment to helping people and promoting responsive environments that support human growth, health, and well-being. Ecology also rests on an evolutionary, adaptive view of the development of human beings. Darwin (1874, 1988) formulated that human beings gradually evolved and were transformed from apes. The premature births of some upright walking apes triggered human evolution. These prematurely born apes may have held on to certain youthful traits longer, and when they mated, their offspring were more likely to be born prematurely and hold on to even more youthful traits. An evolutionary trend may have begun that eventually resulted in a hairless species. The helplessness of these prematurely born infants required support from families, which led to the formation of tribes and communities and created the foundation for human civilization (Capra, 1996). Darwin hypothesized that all forms of life evolved from a common ancestry. In the evolutionary process, a natural selection takes place, in which some

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species survive while others become extinct. For example, if an animal species requires thick fur to survive cold weather, those who wind up with thick fur because of random genetic changes will survive and produce more offspring with thick fur. Those who do not wind up with thick fur will be unable to survive (Capra, 1996). As human beings evolved, they were able to transcend limitations imposed by environmental conditions and the genetic structure of the species that had been developed in the evolutionary past. There were, however, some negative consequences of human development that resulted from cultural rather than genetic changes. We became disconnected from the rhythms of nature that had shaped our physiology and psychology, and we were exposed to conditions of our own creation that were very different from those that had led to our evolution over the millennia. While the concept of evolution unifies all the life sciences, ecology elaborates from the evolution of individuals to the complexity of transactions between organism and their environments. Urie Bronfenbrenner, a psychologist, assumed that individuals affected and were affected by their environments. He was one of the first theoreticians and mental health professionals to apply the biological concepts of systems theory to human growth and development (2005, 1995; 1977). His particular interest was the impact that environmental forces had on child development. Contrary to the mainstream views of the time, which assumed that child development was a largely biological process, Bronfenbrenner argued that healthy child development also depended upon environmental factors Carel Germain, influenced by the writings of Bronfenbrenner (1995; 1977) and René Dubos, a French-American microbiologist (1965;1968), developed the ecological metaphor for our profession (Germain, 1973b, 1976, 1978, 1979) which builds upon and extends concepts drawn from systems theory. She turned to the natural science of biology to explicate ecological concepts. The Life Model of Social Work Practice is grounded in the ecological perspective and includes the following seven assumptions: 1. The reciprocal nature of person and environment exchanges 2. The level of fit between the person and environment and the significance of adaptation 3. The importance of habitat and niche 4. The impact of abuse or misuse of power, oppression, and social and technological pollution 5. Human growth and development affects and is affected by the environment throughout the life course

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6. The existence of life stressors and stress and ways of coping with them 7. The significance of resilience and protective factors

Our model also draws on newer ecological concepts from deep ecology, eco-feminism, and trauma-informed practice. Together, these concepts form the current theoretical foundation of life-modeled practice.

REVIEW OF TRADITIONAL ECOLOGICAL CONCEPTS

Human beings act within physical, social, and cultural environments. Physical environments include the natural and human-made worlds. The social environment includes family, friends, social networks like work colleagues and neighbors, and the community (which also is part of the physical environment). The social environment also includes the wider society within which individuals live and its economic, legal, and social structures. Individuals also exist in a cultural world that includes shared norms, values, traditions, beliefs, and ways of communicating. From an ecological perspective, individuals, families, groups, and communities and their physical/social environments are in continuous reciprocal relationships with one another. Cultural variables influence how these interactions unfold. Reciprocity of Relationships and Transactions

Ecological thinking focuses on the reciprocity of person-environment exchanges, in which each influences the other over time. This mode of thought differs markedly from simple cause and effect. In linear thinking, we assume that an antecedent variable, a, leads to an effect on b at a certain point in time, while a remains unchanged. Linear thinking may explain some simple human phenomena, but only ecological thinking explains the more complex phenomena that we encounter every day in social work practice. Ecological thinking recognizes that a and b are in a reciprocal relationship rather than a unidirectional one. In this situation, a may act in a way that leads to change in b, whereupon that change in b leads to change in a, which in turn affects b—a continuous loop of reciprocal influences over time. Each element in the loop directly or indirectly influences every other element. As social workers, we are less concerned with causes than with consequences and concentrate on helping change maladaptive relationships between people and their environments. We should ask “What is going on?” rather than “Why is it going on?”;

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and “How can the ‘what’ be changed?” rather than “Who should be changed?” Consider the following case: Bryan, 16 years old, wants to be able to stay out late on weekends and not have to always inform his parents, Ron and Suzanne, of his whereabouts. His desire for greater autonomy is consistent with the developmental tasks of adolescence. His parents, particularly his father, Ron, do not appreciate that his desire is ageappropriate; they just want to keep him close and continue to exert control over his actions and decisions. Rather than seeing either the parents or Bryan as the cause of escalating tension (linear thinking), the life-model social worker holds the view that the age-appropriate desires of the son evoke stringent countermeasures from the parents, who don’t understand his developmentally appropriate need for more independence. This disconnect between the son’s wishes and the parents’ demands is likely to lead to increased conflict between them, including Bryan’s rebellion against or total rejection of his parents and their values and expectations. The more his parents demand obedience, the more Bryan rebels, and the more he rebels, the more his parents impose restrictions. This pattern represents a self-reinforcing cycle of negative exchanges.

Instead of attributing the escalation of anger and resentment to either party, the social worker focuses on the family’s transactions and how these increased the tension between them. The social worker also is sensitive to environmental factors that might exacerbate or minimize the tension and recognizes that the family is not a closed system. In this case, the worker learns that Ron has recently lost his job due to company layoffs. His attempts to find other work have been fruitless. He is ashamed and depressed, and he interprets his son’s behaviors as a personal affront. His loss of employment has put financial pressure on the family, since he was the primary breadwinner. The worker also learns that Bryan is having difficulties in school, recently lost a girlfriend, and has been the object of online bullying. Finally, the financial stress, coupled with the tension between Ron and Bryan, has had a negative effect on the marital relationship between Ron and Suzanne, and the strained marital relationship has affected the father-son relationship. When we take these factors into account, it becomes clear that the what in this case goes beyond parent-child conflict and includes Ron’s job loss, Bryan’s school difficulties, financial stress, and marital conflict. These stressors are not mutually exclusive; they are interdependent, with each one influencing the other. At first glance, the worker’s primary task seems relatively straightforward:

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to help parents and son negotiate a compromise that each can live with. To do this, the worker will need to engage in additional tasks, such as assisting Ron with his job search; identifying financial aid and other resources for which the family might be eligible; connecting Bryan with tutoring services; advocating on behalf of Bryan regarding the bullying; and providing supportive counseling to all. The life-modeled social worker focuses on the maladaptive transactions within the family and between the family and the wider environment, rather than simply on changing individuals. Level of Fit

Successful transition over the life course for individuals, families, and groups, as well as successful functioning of communities, depend upon the level of fit with the environment. An adaptive level of fit means that sufficient perceived personal strengths and environmental resources are available to meet current needs, respond productively to life stressors, and support continued growth and development. This leads to a condition of adaptedness (Dubos, 1968). Adaptive person-environment exchanges support and release human potential and growth, health, and satisfaction. Adaptedness is self-reinforcing. As individuals, families, groups, and communities achieve improved levels of fit with the environment, the environment becomes more responsive. A more responsive environment promotes growth and development, which leads to further efforts to improve the level of fit. Poor level of fit results in stress at the individual, family, group, and community levels. It stems from a lack of real and/or perceived personal and collective strengths, as well as limited availability of or access to the resources needed for successful functioning and continued development. A poor level of fit also is self-reinforcing. An unresponsive environment leads to maladaptation and undermines efforts to pursue or enhance adaptedness, which in turn increases the environment’s unresponsiveness. Of interest to social workers are both perceived and actual level of fit. Individuals, families, groups, and communities that encounter inhospitable environments (and are, therefore, unable to make them more responsive to their needs) experience social impotence. Social impotence leads to psychological impotence, which is the belief that attempts to influence the environment will be unsuccessful given past experiences. These two states are self-reinforcing. Social impotence, which reflects a poor level of fit, leads to psychological impotence, which leads the person to believe that the poor fit is inevitable and permanent. The more that clients experience social impotence, the more disabling the stress that

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results. Social and psychological impotence undermine clients’ ability to manage the challenges of everyday life and lead to apathy, resignation, and alienation. The social worker has a threefold responsibility related to improving the level of fit. The first is to help clients to develop new skills and coping strategies to meet the environment’s demands and take advantage of its opportunities. The second is to influence the environment so that the social and physical environments are more responsive to clients’ needs and goals. The third is to change the maladaptive person-environment transactions in order to achieve an improved level of fit. Adaptation is a never-ending process. Adaptedness and adaptation are sometimes confused with passive or conservative adjustments to the status quo. Nothing could be further from the truth. Ecological, life-modeled practice views adaptedness and adaptation as action and change oriented. Social workers help clients become more adept at negotiating with the environment and obtaining needed resources in both the present and the future. In cases where clients experience social impotence and the psychological impotence that results, workers are challenged to understand individual and collective behavior that may at first be interpreted as “lack of motivation,” “disinterest,” or “apathy.” They also must be prepared to provide clients with guidance about how to have an impact on their environment and to support them as they attempt to do so. These two responsibilities are not mutually exclusive and often go hand-in-hand, as the following case example reveals: A social worker, Ellen, is employed in an inner-city elementary school and works with children designated as emotionally and behaviorally challenged. Tyrese, an African American second grader, has been referred to her by his teacher because he has become aggressive toward his classmates, and his teacher is worried that he might hurt one of them or even herself. Tyrese’s mother, his sole caregiver, was invited by the social worker to a team meeting to discuss his educational plan, but she did not attend and provided no reason, which led to anger and frustration and accusations by the team that the mother was “lazy.” The team determined that Tyrese should receive a complete psychological and psychiatric evaluation and assumed that medication would be needed to control his behavior. Ellen, on the other hand, argued that his behavior could reflect his living situation and insisted on contacting his mother to arrange a home visit. Offering to meet Tyrese’s mother in her own home sent a very different and more positive message and resulted in her agreeing to see Ellen. During the visit, Ellen observed firsthand that Tyrese and his family lived in very unhealthy conditions, with peeling paint, a leaky roof, and a rat infestation. His mother reported that she had complained numerous times to the landlord about the problems but nothing

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happened. The mother also reported that one of her other three children was born with special needs, the father of her children was incarcerated for dealing drugs, and she could work only limited hours due to the lack of affordable child care.

From an ecological, life-modeled perspective, five practice issues related to level of fit stand out in this case. First, Tyrese’s behavior is best understood in the context of the inhospitable and stressful environment in which he lives. After further exploration, Ellen discovered that the peeling paint was lead-based. Testing of Tyrese and his siblings revealed that he and one of his sisters had elevated levels of lead in their blood, suggesting that his behavior could be the result of lead paint poisoning. Second, his mother’s “laziness” needed to be understood in context. Her ongoing inability to secure resources that she needed to provide for her family led to a sense of psychological impotence, which resulted in her adopting the understandable attitude, “Why bother? Nothing I do will make a difference anyway.” Third, Ellen will need to help Mom become involved with Tyrese’s education so that she can advocate for his interests. Fourth, Ellen will need to identify resources that can help Mom with child care, employment, and her landlord. Fifth, depending upon the responsiveness of these environmental resources, Ellen may need to directly advocate for the family, teach Mom how to do this herself, or both. Table 2.1 summarizes traditional ecological concepts that are relevant for life-modeled practice.

Table 2.1 Ecological Thinking and Person-Environment Fit Concepts and Their Definitions Exchanges

Continuous transactions between people and their environments, in which each shapes the other over time

Person-environment fit

Favorable or unfavorable fit between the perceived needs, capacities, behavioral styles, and goals of people and the characteristics of the environment

Adaptedness

A favorable person-environment fit that supports human growth and well-being and preserves and enriches the environment

Adaptation

Actions designed to achieve personal change, environmental change, or both in order to improve the level of person:environment fit

Adaptive

Person-environment exchanges that release and support human potential for adaptedness

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Habitat and Niche

In the science of ecology, habitat refers to the places where an organism can be found. Human beings’ habitat consists of physical, natural, and social settings embedded within a cultural context. Physical habitat may be rural, metropolitan, or urban, and it includes residential dwellings, transportation systems, workplaces, schools, religious structures, social agencies, hospitals, and amenities such as parks, recreation facilities, entertainment centers, libraries, and museums. Like any other aspect of the environment, habitats should promote well-being, growth, and development of individuals, families, groups, and communities. Inhospitable habitats lead to isolation, alienation, disorientation, and poor mental and physical health. Niche refers to the place of a species of organism in a community’s web of life. In this book, the term means the status occupied in the wider social structure by individuals, groups, families, and communities. The niche that one occupies is associated with the power to harness resources and influence one’s environment. In turn, power is associated with prestige. Prestige provides both greater access to needed resources and a habitat that promotes growth, development, and well-being. In the case of Tyrese and his family, they occupied a niche in which their power was limited, resulting in substandard living conditions and few options available to his mother to improve their circumstances. Power and Powerlessness

Power and its abuse have always been a part of collective life, but the twenty-first century has brought with it corporate abuses of financial power to an extent not previously seen. As we discussed in chapter one, income disparity continues to grow and wealth has become even more tightly concentrated in the hands of the privileged few. Private corporations and governmental agencies pollute the air, food, water, and soil. Toxic materials continue to be present in dwellings, schools, and workplaces, especially in disadvantaged communities. In politics, lobbyists acting on behalf of large corporations and political action committees (PACs) drive the enactment of legislation rather than what is in the public interest. The election of Donald Trump as U.S. president in 2016 and Republican, one-party control of two of the three branches of government for the first three years of his administration accelerated these abuses at an unprecedented rate. The Democratic sweep of the House in 2018 restored some checks and balances to the executive abuses of power.

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From an ecological perspective, access to power enhances adaptedness and access to resources. Power relationships are self-reinforcing. Those who have it strive to hold onto it and expand their dominance, typically at the expense of those with less power. Those who lack power are unable to access needed resources (social impotence) and, ultimately, they stop trying (psychological impotence). Poverty (particularly deep poverty) is more than just the lack of money. It reflects the self-reinforcing nature of inequitable power relationships. Underfunded schools produce poorly educated individuals at high risk for chronic unemployment, underemployment, and incarceration. Lack of affordable and safe housing results in homelessness and undermines individual, family, group, and community stability and cohesiveness. Limited access to health care results in chronic illness, disabling conditions, and high mortality rates, all of which further undermine financial stability and the potential for increased power. These conditions impose overwhelming adaptive tasks on our most vulnerable and disenfranchised citizens, leading to limited opportunities to exit one’s current niche and ongoing oppression. Life Course

The concept of life course is a far-reaching advance in life-modeled practice. The term refers to the unique pathways of development that each human being and group of human beings takes—from conception and birth through old age for individuals, and from isolation to connection and community for groups. Development takes place in varied environments and includes an infinite variety of life experiences. “Life course” replaces the traditional “life-cycle” models of development, in which “life stages” are assumed to be fixed, sequential, predictable, and universal. The life course concept rests on an ecological view of nonuniform, indeterminate pathways of bio-psycho-social development within diverse environments and cultures. The life course concept emphasizes the following elements: 1. The distinctiveness of human diversity (race, ethnicity, gender, culture, socioeconomic status, religion, sexual orientation, physical/mental states, etc.). The life course concept permits us to individualize personal and collective life experiences instead of forcing all people into predetermined, universal developmental stages. 2. The self-regulating, self-directing nature of human beings and their innate push toward growth and health.

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3. Environmental diversity (economic, political, and social) that accounts for the effects of poverty and prejudicial discrimination on individual and collective development and functioning. 4. Rapid shifts in societal and community values and norms in today’s world. 5. The critical significance of global and local environments.

Life transitions are viewed not as isolated, separable, fixed stages but as ongoing bio-psycho-social processes that occur as individuals, families, groups, and communities continuously interact with their environments. These interactions may be expected or unexpected, promote or inhibit well-being and growth, or create stress or fulfillment. The nature and outcomes of these transactions are the focus of what we do as social workers and what we discuss in this textbook. Life course theorists place human development and social functioning within the context of historical, individual, and social time. Historical time refers to the formative effects of historical and social change on birth cohorts (segments of the population born at a similar point in time) that help account for generational and age differences in bio-psycho-social development, opportunities, and social expectations. For example, the psychosocial development of and opportunities available to the baby boomer cohort, born between 1946 and 1964, and their expectations regarding marriage, parenting, gender roles, and work differ significantly from members of the millennial cohort, born between 1981 and 1997. Social workers need to appreciate differences across cohorts, in addition to the more telling differences in personality, culture, and life experiences, which are understood in terms of individual and social time. The following example reflects the concept of historical time: Joanna, age 53, and Tina, age 30, are both survivors of childhood sexual abuse. Their abuse histories were quite similar. Both were abused during their elementary school years by acquaintances of their family. Joanna’s abuse continued until junior high school and ended when the perpetrator, a neighbor, died. Tina’s family moved away when she was in the fifth grade; this ended the abuse she had experienced by a family friend. Joanna did not disclose her abuse until she was in her forties, explaining later that she was too ashamed to admit what “she had done.” She also indicated that no one “ever” talked about sex, much less sexual abuse, when she was growing up. It wasn’t until she was in her early forties, when she developed crippling anxiety, that she began to understand that she had been molested. Tina disclosed her abuse when she was in high school, after being referred to the school counselor for being disruptive in class. Tina had always known what happened to her was wrong

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because she had learned about “good touch, bad touch” in school. She wanted to tell her parents but feared they would be angry with her because the perpetrator was a close friend. She reported that she was “relieved” when her counselor asked about possible abuse. Both Joanna and Tina experienced shame and guilt about their abuse, which are common reactions among survivors. But these feelings were much more intense and disabling for Joanna. Given her age and the generation in which she grew up, when sex was a taboo topic, she harbored deep, chronic feelings of responsibility for what had happened to her. Even though Tina did not reveal what happened to her until after the abuse had ended, a social environment in which sexual abuse was discussed lessened her sense of responsibility.

Individual time refers to the experiences, meanings, and outcomes of personal and environmental factors over one’s life within a given historical and cultural context. Individual time includes the narratives that we construct about our experiences (Paquin, 2006). These reflect our unique take on the events that occur in our lives. In subsequent chapters, we discuss the importance of inviting and respecting clients’ narratives, which reflect individual time. Paquin observes, “Narratives are the personal stories that people reference as they live their lives. ‘Stories’ arrange events in a temporal sequence and provide meaning to them. These stories determine how people see themselves and others, determine what problems they see in their lives and what those problems mean to them” (2006, p. 130). Consider the case of two sisters, Hannah and Sarah: Hannah and Sarah were both sexually abused. Hannah is the oldest by four years and was the first to seek help, when she was 28 years old. She had been struggling with a drinking problem and recognized that it was connected to her sexual abuse as a child. Once she got into counseling, she decided that she wanted to tell her parents and her other siblings about her abuse. The family was supportive, and during the conversation, Sarah revealed she, too, had been abused as a child. The same 18-yearold neighbor abused Hannah and Sarah. They experienced the same form of abuse at the same age. As they processed what happened to them, it became clear that when Hannah reached a certain age, the perpetrator stopped abusing her and turned to Sarah. Both were abused beginning at age 5 and ending at age 10. The sisters shared certain reactions that are common to survivors of sexual abuse in childhood, like guilt, sadness and loss, and anger. But, there also were marked differences. Sarah expressed much stronger feelings of guilt and maintained that she could have done something to prevent the abuse. She firmly believed that she “must have done something” to have caused her neighbor to abuse her. As a

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young adult, she struggled with self-esteem issues, depression, and social isolation. In contrast, Hannah’s primary reaction to what happened to her was anger at the neighbor, whom she realized took advantage of her and her sister’s trusting natures. Her drinking was a way of “stuffing” these feelings. Hannah wanted to prosecute the perpetrator. Sarah refused, believing that she would be blamed for what happened.

From an objective viewpoint, Hannah and Sarah existed within an identical social environment and faced an identical life stressor. From a subjective, life-modeled perspective, however, each sister had a completely different experience, and therefore reaction to what happened. Social time reflects the transitions, rituals, and expectations that occur within cultural groups. Some of these experiences may be widely shared in a society. For example, in the United States, there is the expectation that once individuals complete their education, they will work and become financially independent. Other transitions may reflect the traditions of specific subgroups. In many Latin American communities in the United States, a 15-year-old girl’s birthday, known as the “quinceañera,” signifies her transitioning into young womanhood and is cause for celebration. Jewish communities celebrate a 13-year-old boy (bar mitzvah) and girl (bat mitzvah) becoming responsible for their religious and spiritual lives. “These rites involve a process of ‘ceasings and becomings’ that involve an individual’s separation from an earlier status and an initiation into, and eventually the full incorporation of, a new status. A key feature of these rites of passage is that they are communal. When we cross these thresholds, it is not just that we think of ourselves differently; it is that others think of us differently too” (Settersten, 2015, p. 219). Social workers are often called upon to assist clients with challenges associated with social time. Clients may choose not to participate in expected transitions and may face criticism for doing so. For example, some couples choose to be childless despite the expectation that parenthood is seen as a normal part of adult life. The traditions of some cultural groups may not be recognized or may be criticized by the society within which the group’s members live. Muslims engage in ritual prayer, known as “salat,” five times a day. Particularly in the anti-Muslim climate that exists in the United States today, this important and solemn ritual is often ridiculed and demeaned. In each of these cases, the lack of needed support is likely to result in stress for individuals, families, groups, and communities. The following case illustrates the challenges that individuals face when they do not have the opportunity or ability to meet the expectations associated with social time:

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From ages 7 to 10, his parish priest sexually abused Timothy. The priest was a close family friend who ate dinner every Sunday with Timothy’s family. At age 28, he referred himself to a social worker at the insistence of his family, who were frustrated at his inability to “get his act together.” Timothy had never told his parents about what the priest had done to him because of their close association. He also had been taught that priests were “next to God” and were not to be questioned. Timothy started college after high school, but he dropped out after one year because he failed all of his courses. He worked a series of low-paying jobs but typically was fired for absenteeism. On two separate occasions, he lived on his own with a friend, but he was unable to pay rent and the roommates grew exasperated with his poor hygiene and unwillingness to keep their apartment clean. Timothy had few friends and had never had a significant romantic relationship. Timothy’s parents gave him an ultimatum: get help with whatever was wrong with him or get out of the house. Timothy’s abuse left him with chronic and intense feelings of inadequacy and self-doubt. He blamed himself for his abuse and assumed that there was something wrong with him. This led him to continually engage in self-defeating and -reinforcing behaviors. Timothy’s abuse left him with few personal resources to successfully navigate the transitions expected of him by his family and the wider society. He also lacked necessary environmental support to assist him with moving forward with his life. Timothy’s family, unaware of what happened to him as a child, exacerbated his stress by constantly criticizing him for his lack of motivation and repeated failures.

Timothy’s childhood abuse affected his ability to meet the expectations that his parents—and the wider social environment within which he and they existed—had for him regarding “growing up” and becoming independent. Therefore, by the time he sought assistance, he had to deal not only with his victimization, but also his self-perceived “failure” to successfully transition into adulthood. In adapting to life experiences accumulated over historical, individual, and social time, human beings change themselves and their environments for good or ill. The reverse is also true. To understand the positive and negative changes, we must understand the interplay of the personal, environmental, cultural, and historical factors that produce change. The implication of these and other elements of the life course concept are expanded in subsequent chapters through their application to practice methods and skills. Table 2.2 summarizes ecological concepts associated with habitat, niche, and the life course.

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Table 2.2 Habitat, Niche, Power, and Life Course Concepts and Their Definitions Habitat

Place where an organism is found. Used metaphorically, all the physical and social settings of human individuals or groups.

Niche

Position occupied by a species in a biotic community. Used metaphorically, the social status occupied in a human community by an individual or a group.

Coercive power

Withholding of power by dominant groups from other groups on the basis of personal or cultural features.

Exploitative power

Abuse of power by dominant groups that creates technological pollution around the world, endangering the health and wellbeing of all people and communities and, most especially, poor people and their communities.

Life course

Unique, unpredictable pathways of development that humans take within diverse environments and cultures, and their diverse life experiences from conception and birth to old age.

Historical time

The historical contexts of social change and its differential formative effects on different birth cohorts (segments of the population born in the same decade or period of time).

Individual time

The life experiences of the individual, the meanings attributed to them, and their outcomes within a given historical context and a particular culture (exemplified by people’s life stories).

Social time

The expected and unexpected transitions, traumatic events, and other life issues in a family, group, or community, and the consequent positive transformations of the collectivity or grave disorganization that may occur.

Life Stressors, Stress, Coping, and Challenge

From a life-modeled, ecological perspective, clients seek, are offered, or are mandated to receive social work services when environmental demands exceed their capacity to meet them; their needs exceed the environment’s ability to respond; they lack the ability to successfully negotiate their environment to access the resources and support they need; and/or the environment is unresponsive to their needs. It is unlikely that clients will view their situation in this way, but as social workers, we view our clients’ challenges transactionally. Life stressors lie neither solely within the client nor within the environment. Clients’ difficulties result from the continuous interplay between them and the bio-psycho-socialeconomic environment within which they live.

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Life stressors reflect the negative, maladaptive relationships that exist between clients and their environments. A stressor may be a specific event or circumstance, like a natural or human-made disaster, job loss, death of a loved one, domestic violence or child abuse, or a house fire. It may be an ongoing condition, like living in poverty or with a chronic mental or physical health problem. It may be a single incident or consist of multiple circumstances over short or long periods of time. Stress is a client’s response to life stressors. It affects individuals’, families’, groups’, and communities’ physiological, behavioral, social, emotional, and/or cognitive functioning. Frequently, all five aspects of functioning are affected. However stress is manifested, it results in the self-defeating and reinforcing cycles described previously. Consider the following scenarios: Sally Newton, age 7, was admitted to the hospital complaining of severe headaches. Diagnostic tests revealed that she had advanced, inoperable brain cancer. Chemotherapy and radiation treatments were administered to prolong her life and ease her symptoms, but doctors informed her parents that she would likely have only six months to a year to live. Sally lived for four months, passing away at home surrounded by her family. The outpatient oncology clinic provided social work services to Sally as well as to her family (Mom; Dad; sister Amy, age 12; and brother Sammy, age 9), during her treatment and after her death. All the members of the Newton family experienced emotional reactions, including grief, guilt, and anger (at God, at fate, etc.). Mom and Dad also experienced anxiety as they attempted to deal with the financial costs of Sally’s treatment. Mom’s physical functioning was compromised due to grief and resulted in loss of weight, anxiety, and depression. The family’s social functioning also was affected; as often happens when a child dies, Mom and Dad began arguing. This reflected distortions in their cognitive functioning based upon their need to find someone or something to blame for Sally’s cancer. Both Amy and Sammy began having behavioral problems in school that included failing grades and hostile behavior toward peers. School social workers determined that the siblings’ behavior reflected their cognitive beliefs that it should have been them who died, not their sister, reflecting survivor’s guilt. The Newtons also began to isolate themselves from family, friends, and their local community, depriving them of the support they desperately needed and exacerbating the stress they experienced. The Morningside Hill neighborhood is in very poor part of a large city. A total of 65 percent of the families that reside in the Morningside Hill ZIP code live below the poverty line. The unemployment rate among adults (ages 18–60) is

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54 percent. The stress associated with living in this community is evident in a variety of ways. Physiological problems include high rates of infant mortality, heart disease, and lung cancer relative to other, more privileged communities in the same city. Gang violence, high rates of drug addiction, and a murder rate that is triple that of other neighborhoods in the same city reflect the behavioral challenges the community faces. Social problems include lack of connections or a sense of community among residents. Residents report emotional problems like depression and anxiety. Efforts by social workers employed in a community support center to mobilize residents to fight crime and blight have been met with disinterest, distrust, and apathy, each of which reflects the psychological and social impotence discussed previously. Psychological and social impotence reflects the cognitive and emotional changes that result from stress.

At first glance, these case examples seem quite different. One concerns a family and the other an entire community. The life stressors also differ—death of a child (acute) and living in sustained poverty (chronic and ongoing)—as do the manifestations of stress. From the life-modeled, ecological perspective, the underlying challenges—and therefore the social worker’s role—are quite similar. In both illustrations, the social worker strives to enhance clients’ ability to cope with current circumstances and improve their adaptive capacities to meet future challenges. This will include working directly with the client—the Newton family in one case and the community in the other—and improving linkages between the client and the wider environment. Coping with life stressors depends upon characteristics of the stressor, as well as individuals’ families’ groups’ and communities’ reactions and the nature of transactions between them and their environment. Effective coping requires internal and environmental resources. Internal resources for coping include motivation; management of feelings; problem-solving; relationship skills; a hopeful outlook; self-esteem, self-efficacy, and self-direction; the ability to identify and use information from the environment about the stressor and how to deal with it; self-restraint; and an ability to seek environmental resources and to use them effectively. Flexibility also facilitates coping. Like hope, it reflects a recognition of positives despite the stressor, a trust in the certainty of future satisfaction, and an ability to seek and accept help when needed. Environmental resources include formal service networks such as public and private agencies and institutions. Individuals’ access to these resources is defined by societal and cultural notions of “worthiness” and reflected in eligibility criteria, as well as organizations’ need to carefully allocate scarce resources through hours and length of service. Resources also include informal

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networks of relatives, friends, neighbors, work colleagues, schoolmates, and fellow congregants. These support networks serve as buffers against stress and fill the void created by limits placed on the use of formal services. Even the perception of their availability can make it easier to cope with a life stressor by altering expectations. The natural and built physical environment (parks, oceans, transportation, and dwellings) also contribute to well-being and support coping efforts. When efforts at coping are ineffective, stress is likely to be intensified, which diminishes adaptability. The stress generated in one area may cause other stresses, so multiple stressors become involved. Research Findings: Stress and Coping

Hurricane Katrina hit the Gulf Coast of the United States in 2005 and proved to be the costliest and third-deadliest storm to hit that area since the 1990s (Adeola & Picou, 2014). The storm hit three of the poorest states in the nation (Alabama, Louisiana, and Mississippi). “Katrina destroyed almost everything along its regional path, disabled local response systems, displaced almost one million survivors, and continue(d) to have severe adverse consequences [for many years]” (Adeola & Picou, 2014, p. 122). The physical destruction that Katrina left behind was enormous. But the storm’s socioemotional consequences—the stress responses of its victims—had an even greater consequence. Hurricane Katrina represents a life stressor that was unexpected, unpredictable, acute, and out of anyone’s control. Studies have revealed that most of Katrina’s victims—who endured its destructiveness firsthand, lost loved ones, homes, and property, or both—experienced depression, anxiety, and indicators of posttraumatic stress disorder in the immediate aftermath of the storm and for years afterward (Adeola, 2009). The research also revealed that these consequences were not equally distributed across age, race, gender, or social class of victims. Differences in the severity and longevity of responses varied by region, with those residing in the poorest parts of the Gulf Coast experiencing the most severe reactions (Adeola & Picou, 2014; Freudenberg, Gramling, Laska, & Erikson, 2009; Glass, Flory, Hankin, Kloos, & Turecki, 2009; Munasinghe, 2007). In New Orleans, the parishes that were hardest hit had rates of poverty that were twice the national average (LaJoie 2010). Since persons of color, children, the elderly, the disabled, and immigrants were more likely to be poor, these groups also showed signs of more debilitating and long-lasting emotional problems and disrupted social functioning than others (Kim, Plumb, Gredig, Rankin, & Taylor, 2008).

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Researchers offer at least five explanations for these findings: 1. The physical environments in these regions were substandard prior to the storm, leading to more severe devastation and limited resources afterward to assist with recovery. 2. Poor communities lacked cohesion. Residents were disconnected from one another prior to the storm and could not serve as sources of support during or afterward. 3. Poor residents also struggled with what we have referred to as psychological impotence prior to the storm. Thus, an event truly beyond their control served to reinforce this belief, and therefore the despair and depression to which it leads. 4. The devastation in these communities resulted in mass evacuations, with residents being forced to relocate, often for long periods of time, to places where many had no contacts or connections. This displacement itself contributed to victims’ distress. 5. Citizens who were particularly vulnerable prior to the storm—children, the disabled, and elderly—lacked the personal resources to cope effectively.

In sum, research findings regarding the impact of Katrina revealed that the individuals and communities least able to cope with the hurricane were those most affected. A very different type of life course event is the transition to parenthood. This is an event that is expected, often planned, and assumed to occur at a particular stage of the life course. It also is an event that individuals can (but do not always) control. In these ways, it stands in stark contrast to an event like Hurricane Katrina. Research suggests that even under the best of circumstances, this transition can create challenges, particularly in the relationship between the biological parents (Mitnick, Heyman, & Smith Slep, 2009). Findings suggest that even in committed relationships in which both partners looked forward to the birth of a child, there is at least a temporary disruption in the relationship. This results from the physical demands placed upon them by the newborn, the difference between the reality of parenthood and what was expected, conflicting expectations between partners as to their role and responsibilities, and interruption in the sexual relationship (Lawrence, Nylen, & Cobb, 2007). This transition has been found to be even more challenging for different groups. We focus on one here: lesbian, gay, bisexual, transgender, and queer/ questioning (LGBTQ) parents. While parenthood for LGBTQ individuals has become more commonplace, they often experience greater challenges

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transitioning to the role of parents than heterosexual couples due to societal views of their appropriateness for this responsibility. Stigma has been a significant aspect of parenting for LGBTQ individuals (Moore & Stamboulis-Ruhstorfer, 2013). Cao, Mills-Koonce, Wood, and Fine (2016, p. 31) note, “The . . . challenges include the prevailing concerns stemming from a heteronormative model of family and parenthood . . . that question the appropriateness of a same-sex coparenting environment for children’s ‘proper’ development.” These authors further observe that LGBTQ parents also may be stigmatized within their own community due to the assumption that parenthood is inconsistent with their status as sexual minorities. Research findings suggest that in addition to the normative challenges that heterosexual couples face, sexual minorities face other struggles that may compromise their ability to successfully master the transition to parenthood (Cao et al., 2016), such as the following: 1. The means of conceiving a child and becoming a parent (e.g., artificial insemination, surrogacy, and adoption) are expensive and stressful. 2. The expectations and duties associated with parents’ respective roles, such as two “mommies” or two “daddies,” are ambiguous given the lack of precedent. 3. Practical issues that usually do not come up, like the child’s last name and legal status, must be negotiated.

Factors that facilitate LGBTQ individuals’ transition to parenthood include support in the form of financial resources (to pay for artificial insemination, surrogacy, and adoption), practical assistance with the traditional challenges, and acceptance by significant others like family and friends (Goldberg & Gartrell, 2014). In general, individuals, families, groups, and communities adapt and cope relatively well with difficult life stressors. As the case examples and research findings reveal, however, the interplay of characteristics associated with individuals, families, groups, and communities, the specific stressors, and the environmental context ultimately determine the outcome. Ideally, we grow as we cope with stressors. Our self-esteem, sense of competence, connection to others, self-direction, and ability to cope with future challenges may be enhanced by triumph over adversity. We now turn to these possibilities, as well as the factors that promote recovery and growth following stressful life conditions. Table 2.3 summarizes the life stressor conceptualization.

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Table 2.3 Stressor, Stress, and Coping: Definitions Life stressor

Life transitions, traumatic events, and environmental and interpersonal pressures that disturb the level of personenvironment fit and a prior state of relative adaptedness.

Stress

Internal (physical or emotional) responses to a life stressor that exceeds one’s perceived personal and environmental resources to cope with it.

Primary appraisal

Conscious or unconscious processes through which a person judges whether an issue is irrelevant, benign, or a stressor. If the latter, it might pose harm or loss (damage already suffered), a future threat of harm or loss associated with an anticipated life issue, or a challenge (anticipated mastery). A stressor is associated with negative feelings, while a challenge is associated with positive feelings.

Secondary appraisal

Consideration of measures and resources to deal with a life stressor.

Coping

Behavioral and cognitive measures to change some aspect of oneself, the environment, the exchanges between them, or all three, in order to manage the negative feelings aroused.

Feedback

Error-correcting internal and external signals and cues from a person’s cognitions and sensory perceptions, and from the environment about the effectiveness of the coping efforts.

Resilience and Protective Factors

Resilience theory explores the factors that contribute to individuals’, families’, groups’, and communities’ ability to bounce back when faced with stressors. It is an important feature of life-modeled practice. “Resilience theory attempts to answer questions such as the following: Why are there such significant variations among individual, familial, and community responses to adversity and trauma? Why do some . . . adapt, cope, and meet the challenges of physical and mental impairments, severe losses, chronic discrimination, and oppression, and others don’t? . . . In sum, what accounts for this hardiness?” (Gitterman & Knight, 2016, p. 2). The answers to these questions lie in person-environment transactions. Distress in response to life stressors reflects individual, family, group, community, and environmental factors. Resilience also is transactional in nature. It does not mean that individuals or collections of individuals do not experience discomfort or disruption in response to life’s stressors. It means that when faced with adversity, they may regress and lose some power and capability, and yet recover and

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return to a prior level of adaptation. Protective factors are biological, social, psychological, and environmental processes that contribute to preventing a stressor, lessening its impact, or ameliorating it more quickly (Carp, 2010; Gitterman & Sideriadis, 2014). Over the last two decades, increased attention has been focused on differentiating victims from survivors: those who succumb to stress and those who are able to overcome it. This is consistent with the social work profession’s commitment to and goal of empowering clients and building upon strengths. There is some variation in what constitutes a protective factor, but the findings of numerous studies consistently identify traits and qualities at the individual, collective, and community levels. Individual characteristics include intelligence and appraisal skills, coping and problem-solving skills, self-esteem and self-efficacy, temperament, spirituality, and general outlook on life (Rice & Girvin, 2010; Smith-Osborne & Whitehill Bolton, 2013). Flexibility and creativity also contribute to hardiness, as do a willingness and ability to seek support. Humor, an additional protective factor, has a profound impact on everyday interactions (Gitterman, 2003a). For oppressed and vulnerable populations in particular, humor and laughter provide safety valves for coping with painful realities. Religious, ethnic, and racial humor helps a stereotyped group to vent anger and to dismissively laugh at the dominant culture’s stereotypes. The most important protective factor for collections of individuals—families, groups, and communities—is a sense of cohesiveness and mutual support. This is reflected in the sentiment “we are in this thing together” (Cardoso & Thompson, 2010). Analogous to protective factors for individuals, flexibility, the ability to “think outside the box,” seek resources and support, and appraisal skills foster resilience at the collective/community level (Knight, 2017). Shared cultural beliefs and traditions also contribute to hardiness (Vesely, Letiecq, & Goodman, 2017). Environmental elements that contribute to individual, group, family, and community resilience stem primarily from characteristics of social institutions. Institutions in existence prior to a stressful event that are responsive to individual and community needs, well known and publicized, and work in a coordinated fashion promote resilience. Resilience also is supported when a network of services can be rapidly deployed following a disruptive event (Colton, Grimsmore, & Simms, 2015; Cox & Elah Perry, 2011). Also important is the availability of federal, state, and local funds to respond, rebuild, and move forward following a stressful occurrence (Colton et al., 2015). When environmental resources are lacking and when the physical/biological and built environments are substandard or even toxic, human capital is diminished, as is resilience (Hanna, Dale, & Ling, 2009).

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Adversarial Growth

The notion of adversarial growth builds upon the concept of resilience and focuses on the ways in which individuals, families, groups, and communities not only survive life stressors, but thrive and grow from them (Bonanno, 2005; Linley & Joseph, 2004). Adversarial growth is a more recent conceptualization, and research and theory so far have mostly focused on individuals. Findings suggest that a potential benefit of adversity is that it may lead to improved coping capacities and an enhanced ability to manage future challenges (Seery, Holman, & Silver, 2010). Exposure to and surviving life stressors may provide individuals with an opportunity to evaluate their priorities, enhance or create a sense of spirituality, and prompt them to live their lives in more fulfilling ways. Adversity also can create in individuals more empathy and sensitivity toward others (Bonanno, 2005; Linley & Joseph, 2004; Rutter, 2013). Table 2.4 summarizes nature of resilience and protective factors. Table 2.4 Resilience and Protective Factors: Definitions Resilience

Ability to bounce back from stressful events

Protective factors

Biological, psychological, social, and/or environmental processes that lessen the impact of stressors

Risk factors

Biological, psychological, social, and/or environmental processes that exacerbate the impact of stressors

Protective factors Individuals

• Intelligence and appraisal skills • Coping and problem-solving skills • Self-esteem and self-efficacy • Temperament • Spirituality • Outlook on life • Willingness to seek support • Flexibility and creativity • Humor

Protective factors Groups, families, communities

• Cohesiveness and mutual support • Flexibility and creativity • Cultural beliefs and traditions

Protective factors Environments

• Availability and responsiveness of institutionalized support • Coordinated network of services • Availability of funding

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Research Application: Resilience and Adversarial Growth

Hurricane Sandy, which hit the mid-Atlantic coast in the most densely populated region of the United States in late 2012, provided researchers with yet another opportunity to examine the impact of stress at the individual and community levels. This storm spanned more than 1,000 miles and devastated large swaths of the New Jersey shore and severely damaged parts of downtown Manhattan, other New York City boroughs, and nearby coastal cities and towns. More than 100 individuals lost their lives, and damage estimates climbed to more than $75 billion (Boscarino et al., 2013). An important contribution of the research into Sandy was the attention devoted to identifying the protective factors that promoted resilience and adversarial growth (Cagney, Sterrett, Benz, & Tompson, 2016; Comes & Van de Walle, 2014; Cutter, Schumann, & Emrich, 2014; McArdle, 2014; Shira, Palgi, Hamama-Raz, Goodwin, & Ben-Ezra, 2014; Tompson, Benz, Aglesta, Cagney, & Melt, 2013). Chief among the findings were the following: 1. Support from friends, families, and neighbors was a key predictor of individual resilience. 2. Concrete, material support was most helpful and included providing housing, assistance with cleanup, and essentials like groceries, clothing, and other staples. 3. Social cohesion—or a sense of connectedness to others—enhanced both community and individual hardiness. 4. Advance preparation and knowledge contributed to individual and community resilience. Individuals and communities that were informed about the storm’s approach and its projected impact and could take steps to protect themselves and their property fared better than those who did not or could not do so. 5. The ability to stay connected and informed during the storm and afterward and the availability of and the ability to use social media and the Internet enhanced resilience. 6. Financial resources, including insurance coverage, contributed to resilience. 7. The availability of, easy access to, and quick response of public and private sources of assistance following the storm enhanced individual and community hardiness. 8. Older individuals—but not younger ones—who had been directly affected by the September 2001 terrorist attacks in Manhattan exhibited fewer mental health problems after Sandy, suggesting the existence of stress inoculation. 9. Individuals who had experienced hurricanes in the past were somewhat less likely to be distressed than those who had not.

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Trauma and the Life Course

Research indicates that most adults 18 years of age or older have been exposed to at least one traumatic event in their lifetime (Benjet et al., 2016). Research also reveals that a disproportionate number of clients seen in agencies in which social work students are placed and professional social workers practice have a history of trauma exposure (Becker-Blease, 2017; Branson, Baetz, Horwitz, & Hoagwood, 2017). These include child welfare, forensics/corrections, health and mental health, school, homeless, and family services, and addiction settings. Therefore, social work educators, practitioners, and researchers have turned their attention to trauma and its impact on those who experience it. A traumatic event is one that creates overwhelming stress that weakens or destroys individuals’, families’, groups’, and communities’ ability to cope with and manage that event. Until relatively recently, the assumption was that events in themselves led to psychological trauma. In some instances, this is the case, but evidence increasingly reveals that whether an event is experienced as traumatic depends upon a complex interplay of intrapsychic, interpersonal, cultural, social, and environmental factors. Prior emotional, social, psychological, and cognitive functioning, as well as the availability of social and community support, can minimize or intensify the traumatic impact of an event (Sippel, Pietrzak, Charney, Mayes, & Southwick, 2015). These research findings are consistent with our previous discussion of life stressors, coping, resilience, and adversarial growth. Even for an event that strikes most, if not all, of us as horrific—a mass shooting, for example—the individuals exposed to it experience it in their own unique way. Some will be more traumatized than others. Some will bounce back quickly, demonstrating resilience, and others will struggle to move on and return to normalcy. A considerable body of research demonstrates that when individuals, families, groups, and communities are traumatized in response to natural and human-made disasters (for example, plane crashes, mass shootings, hurricanes, and earthquakes) and interpersonal victimization (for example, community and domestic violence), they are likely to experience significant long-term difficulties. This is especially true when the victimization is experienced in childhood in the form of physical and particularly sexual abuse. Common long-term challenges include behavioral problems like addiction, self-harm, and aggression and emotional and psychiatric problems like depression, anxiety, and stress disorders. Trauma exposure also undermines survivors’ ability to successfully engage in social relationships. A low sense of self-esteem, self-worth, and

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self-efficacy leads to distortions in thinking about self and others (Farrugia et al., 2011; Shafer & Fisher, 2011). At the community level, trauma exposure reduces cohesiveness and increases isolation and alienation among members (Adeola & Picou, 2014; Luckman, Strafer, & Lipski, 2016). Of relevance to the life-modeled approach to helping, these challenges also undermine individuals’, families’, groups’, and communities’ ability to successfully negotiate and manage the transitions that are normal and expected aspects of the life course. An individual who was sexually abused in childhood may struggle with specific challenges like substance abuse issues and depression and are at risk of being unsuccessful at mastering life transitions like developing intimate relationships, obtaining employment, and the like. Because of the unique challenges faced by trauma survivors and the fact that, as social workers, we are likely to encounter them in our practice, emphasis is increasingly placed upon educating students for trauma-informed (TI) practice. The assumptions that underlie this perspective will be elaborated upon in subsequent chapters. In brief, a TI orientation requires that social workers understand that the ways in which many current clients’ problems should be understood is in the context of past trauma exposure (Knight, 2015). Social work services that are available to clients in the immediate aftermath of a traumatic event through services like rape crisis and domestic violence, and those that arise in response to an unexpected event like a mass shooting or natural disaster are likely to operate from a TI/crisis-oriented perspective. However, the settings that are most likely to serve trauma survivors are those that address current stressors in living rather than the underlying trauma that might explain (or at least be connected to) it. It is these settings in which students are most likely to be placed. This presents students (and their field instructors) with unique challenges as they help clients with their life stressors in the present, but also acknowledge past trauma in a manner that is consistent with their agency-defined role. The following are examples drawn from our students’ field experiences: • Denise was assigned to a shelter for homeless veterans. Her client, Ricardo, had a long history of substance abuse, which resulted in his loss of jobs and rejection by family and friends. She was helping him transition into community housing, secure employment, and remaining sober. In one of their sessions, Ricardo tearfully described how he saw two close buddies “blown to bits” by an improvised explosive device while he was deployed in Afghanistan. • Tyler worked in an after-school program for adolescents who were involved with the juvenile justice system. His client, Darius, had been charged with carjacking

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and was required to attend the program to help with school attendance and job readiness. Darius disclosed that when he was 8 years old, he witnessed his father murder his mother by stabbing her multiple times with a knife. He was placed in a series of foster homes, where he was physically and sexually abused. • Madeline worked in a shock trauma setting and was responsible for providing short-term support—which often consisted of grief counseling—to the loved ones of the patients, many of whom died as a result of their injuries (typically from shootings or car accidents). The son of her client, Jenise, had been murdered in a drive-by shooting. Jenise disclosed that as a child, she had been sexually abused by her father and uncle. • Serena was placed in foster care and was facilitating an eight-session parenting group for biological parents who had lost custody of their children and were working toward reunification. After one member disclosed a history of physical and sexual abuse in childhood, other members revealed similar traumatic experiences in childhood and adolescence.

In subsequent chapters, we will explore how social workers can work within their defined roles but still be helpful to clients who have histories of childhood trauma.

ADDITIONS TO THE ECOLOGICAL PERSPECTIVE

Two newer sets of ecological concepts emerge from deep ecology and ecofeminism. These concepts extend and refine our understanding of the complex transactions between people and their environments. Deep Ecology

Deep ecology focuses on the interconnectedness and interdependence of all living organisms (Naess, 1989; Reed & Rothenberg, 1993). Living systems—including individuals, families, groups, and communities—are viewed as networks interacting with other systems of networks “in an intricate pattern of intertwined webs, networks nesting within larger networks” (Capra, 1996, p. 82). These patterns are nonlinear. Living systems are constantly influencing and being influenced by one another, which results in new behaviors and patterns of interaction. The interdependence of networks and self-correcting feedback loops requires systems to adapt to changing conditions as a way of surviving disturbances and continuing growth and development. The interdependence of networks,

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self-correcting feedback loops, and the cyclical nature of ecological processes are the basic principles of deep ecology as is the notion of flexibility. The precepts of deep ecology suggest that individuals, families, groups, and communities affect and are affected by both the biological and physical, human-made environments (Besthorn, 2012). Current problems in the physical, biological environment often stem from human actions. Climate change, poor water quality, high levels of pollution, and the like have implications for individuals’, families’, groups’, and communities’ physical, mental, and financial health (McMichael, Woodruff, & Hales, 2006; Stern, 2007). These problems also disproportionately affect the poor and other vulnerable populations around the world, as was observed in studies of the impact of Hurricanes Katrina and Sandy. A final concept of deep ecology, social sustainability, reflects the assumption that what we do in the present has implications for the future (McKinnon, 2008). The consequences of ignoring this reality are apparent when we consider the environmental changes associated with the warming of the planet: rising sea levels, increasingly destructive weather events like hurricanes, and significant changes in precipitation patterns that result in droughts and flooding. These changes have resulted in an increase in, among other things, water-borne and other biologically based diseases, crop and livestock loss, and property damage (Mishra, Singh, & Jain, 2010). The interdependence of humans with their environment and escalating environmental degradation underscore the need for social workers to engage in advocacy and lobbying efforts at the local, state, federal, and worldwide levels (Miller, Hayward, & Shaw, 2012). These interventions have become even more critical in the United States given the current political environment, where climate change is ignored in support of corporate and industrial interests. Social work also will have a critical role to play in promoting social sustainability through intervention at the micro, mezzo, and macro levels (McKinnon, 2008). The following list summarizes the principles associated with deep ecology: • • • • •

Networks are intertwined and interdependent. Networks are constantly influencing and influenced by one another. Networks are self-regulating, learning from and correcting mistakes. Networks spontaneously create new adaptive behaviors. Individuals, families, groups, and communities affect and are affected by physical, human-made, and natural environments. • Problems in physical and natural environments often stem from human actions.

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• Problems in physical and natural environments disproportionately affect vulnerable populations. • What humans do in the present has implications for the future (social sustainability).

Ecofeminism

Feminist scholars brought awareness of gendered roles in family, work, political, and economic life, as well as historical and contemporary violence against women. Concepts from feminist theory have been integrated into the education and practice of many, if not most, social workers over the past 30 years. Feminist social work scholars called specific attention to some points of convergence in the feminist perspective and the ecological perspective and life model in social work: Feminist analysis mandates viewing reality in a holistic, integrated, and ecological fashion. The ecological perspective pertains to the interrelatedness inherent between persons and their environments (Van Den Bergh, 1986, p. 4).

Adherents to ecofeminism apply the same critical lens to the relationship between humans and their environment as they do to male-female relationships. Ecofeminists argue that the pursuit of wealth and economic advancement has been at the expense of the natural environment (Uggla, 2010). Oppression of women and destruction of the environment are two sides of the same coin, reflecting patriarchal, exploitative relationships (Norton, 2011). Ecofeminists took up the causes against toxic waste, animal abuse, deforestation, and nuclear disarmament. From an ecofeminist perspective, social justice includes protecting the Earth’s resources, in addition to enhancing the rights and well-being of those who inhabit the planet. Strategies for change emphasize nonviolence, passive and active resistance, and political activism locally, nationally, and internationally. Ecofeminism perspectives deepen and enrich ecological theory and life model practice. We now turn our attention to applying the concepts presented in this chapter to social work practice.

The Life Model of Social

THREE

Work Practice An Overview

ORIGINS AND DEFINING CHARACTERISTICS OF LIFE-MODELED PRACTICE

The Life Model of Social Work Practice is rooted in the philosophy and traditions of the settlement house and charity organization movements. Consistent with the charity organization society (COS), life-modeled social workers intervene to improve clients’ lives in systematic ways. The settlement house workers recognized the broader social, economic, and political forces that contributed to their clients’ distress and sought to ameliorate them. They viewed their community members as deserving of their respect and as equals. They did not attempt to do anything to their neighbors and group members; they worked with them in partnership. Life-modeled practice involves four distinct phases: preparatory, initial, ongoing, and ending. Each phase has associated professional methods and skills. In subsequent chapters, we elaborate upon these phases and the methods and skills associated with each. The actual term was inspired by the work of the late Bernard Bandler, a Boston psychiatrist who worked closely with social workers. In advancing egosupportive practice in social work, Bandler (1963, pp. 42–43) introduced the

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idea of modeling practice on “life itself, its processes of growth, development, and decline, its methods of problem-solving and need-satisfaction as understood in the trajectory of the life span.” Life-modeled practice fits the social work profession’s purpose of releasing the potential for growth and satisfying social functioning of individuals, families, and groups, while increasing the responsiveness of the environment to their needs, rights, and aspirations. Bandler challenged social workers to learn from people who cope effectively with the inevitable stressors in life. Instead of relying on artificial clinical processes, social workers can utilize these real-life processes in interventions that will mobilize forces of health and continued growth and relieve environmental pressures. A total of 11 features, in a unique combination, characterize life-modeled practice: 1. Professional function, which includes practice with individuals, families, groups, and communities, as well as organizational influence and political advocacy 2. Ethical practice 3. Diversity-sensitive and culturally competent practice and cultural humility 4. Empowering and social justice practice 5. Integrated modalities, methods, and skills 6. The need to engage in evidence-guided practice 7. The client/worker relationship as a partnership 8. Assessment as a process and a product in which clients are the experts about their own lives 9. Focus on personal and collective strengths, resilience, and client action and decision-making 10. The need to attend to clients’ social and physical environments and culture 11. Phases of the helping process

Social Work Professional Function

The purpose of life-modeled practice is to improve the level of fit between people and their environments, especially between human needs and environmental resources. In providing direct services to individuals, families, groups, and communities, the social work purpose is to help clients mobilize and draw on personal and environmental resources to (1) eliminate or alleviate life stressors and the associated stress, and (2) influence social and physical environmental forces to be responsive to people’s needs.

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As described in chapter two, most people confront life stressors in one or more aspects of living: difficult life transitions and traumatic life events, environmental pressures (including poverty and oppression), and maladaptive processes in family, group, or community functioning. Life transitions include developmental (biological) and social changes in status and role. Traumatic life events are often unexpected; they include grave losses such as the death of a child, natural and human-made disasters, interpersonal and community violence, and sexual assault. Environmental pressures can arise from the lack of resources and social provisions in the social and physical environments. This might include destructive or nonsupportive social networks, organizations that arbitrarily withhold resources, and the perpetuation of poverty, violence, and other major social problems. Physical settings can be serious life stressors because of deteriorated dwellings and neighborhoods that may lack amenities of any kind. Maladaptive communication and relationship patterns in families, formed and natural groups, communities, and human services organizations can also create serious life stressors. When a life stressor surfaces and is not successfully managed, additional stressors can erupt in other areas of life, as the following example reveals: The Williams family consists of the parents and two daughters, one in high school and the other in kindergarten. Mr. Williams was a valued employee of a moving company until he began to suffer migraine headaches and fainting spells, accompanied by progressive alcoholism. Eventually, he was suspended from his job. Nevertheless, his employer is eager for his return—but only with medical assurance that the fainting spells, headaches, and alcoholism are under control. However, Mr. Williams’s health insurance does not provide mental health coverage for services like addiction treatment. He is on various medications, prescribed by several doctors, on which he is becoming increasingly dependent. When Mr. Williams lost his job, he also lost the status and self-esteem he had gained as a successful professional mover. This undermined his sense of competence, intensified his depression, and worsened his drinking problem. He also needs help in considering hospital detoxification programs but lacks the financial resources to pay for this much-needed treatment. Mrs. Williams works part time in a fast-food restaurant and has no benefits. She has become the dominant force in the family as her husband’s condition deteriorated.

Life stressors appear in the following areas: 1. The family faces eviction because Mr. Williams’s troubles resulted in nonpayment of rent and complaints about his noisy behavior.

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2. Mr. Williams now occupies the niche of “helpless alcoholic.” He enacts the role of victim, sleeping late and withdrawing from family life. Reciprocally, Mrs. Williams encourages him to stay away from home, treats him as if he were a naughty child, scolds him, and withholds money. Their conflict has become increasingly severe, marked by physical violence, emotional explosions, and absence of sexual intimacy. 3. Mr. Williams is withdrawing from his children, and the children are beginning to withdraw from both parents. The older daughter is beginning to have difficulties in school. 4. Mr. Williams lacks the financial resources to pay for the treatment he needs to help him with his drinking problem, since his insurance will not cover it.

These stressors are interrelated and self-reinforcing. Life-modeled practice with the Williams family would intervene at the individual, family, and environmental levels to prevent further disorganization. Focusing solely on Mr. Williams would ignore the impact that his behavior and situation have on the rest of the family and that the family has on his behavior and situation. Focusing solely on the family would ignore the individual challenges Mr. Williams faces. And concentrating only on the family and Mr. Williams discounts the role that the environment—the lack of financial resources and of parity between his insurance coverage for physical versus mental health services—plays in contributing to the problems they face and the solutions that are required. Family members would be helped to set priorities among the stressors to be worked on immediately as opposed to later, and the social worker would seek out personal, family, and environmental strengths and resources. Social workers mediate the exchanges between people and their environments in response to the lack of fit between clients’ perceived needs and their personal and environmental resources. The purpose of life-modeled practice also includes professional responsibility for bearing witness against social inequities and injustice. This is done by mobilizing community resources to influence the quality of life for individuals, families, groups, and communities, by influencing unresponsive organizations to develop responsive policies and services, and by politically influencing local, state, and federal legislation and regulations to support social justice. In the Williams’ case, the social worker engaged in life-modeled practice would need to intervene in the environment in two ways: securing financial resources to help the family pay their rent and addressing Mr. Williams’s need for addiction treatment. This might involve advocating on his behalf with his insurance company, locating a program that offers free or low-cost addiction

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Environmental Pressures

Difficult Life Transitions and Traumatic Events

Client and Worker Maladaptive Family/Group/ Community Processes

Figure 3.1 Professional Function and Life Stressors

treatment, and/or acquiring financial assistance that would cover the cost of his treatment. The professional function is represented in figure 3.1. The social worker engaged in direct practice may be unable to address the broader social forces that are at play in this example—inadequate health insurance and the lack of a social safety net to help clients in time of need. However, life-modeled social workers understand that they have a responsibility to empower clients to more successfully navigate their social and physical environments. We identify ways that the social worker can do this in chapter nine. In chapters fourteen, fifteen, and sixteen, we discuss strategies that social workers utilize when they challenge these forces. The broader professional function is represented in figure 3.2. Community

Organization

Social Policy and Legislative Process

Social Worker

Figure 3.2 The Life Model Social Change Conception of Professional Function

Ethical Practice

Social work is a profession committed to improving the lives of individuals, families, groups, and communities, as well as the responsiveness of organizations. Toward this end, the profession has established a set of principles and values to which all practitioners must adhere. Core values include respect for all and for diversity and commitment to social justice, equality, and nondiscrimination.

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The Code of Ethics of the National Association of Social Workers (NASW) identifies social workers’ obligations based upon these values https://www.socialworkers.org/pubs/code/default.asp). The NASW was established in 1955 when seven professional organizations consolidated into one. Social work associations that targeted specific groups of social workers joined forces with the American Association of Social Workers and the Social Work Research Group. By consolidating these various associations under one umbrella organization, social work’s professional identity and core principles and values were solidified. NASW’s Delegate Assembly approved the profession’s first Code of Ethics in 1960. The code defined what it meant to be a social worker and identified 14 associated responsibilities. Its first revision occurred in 1967, when the core value of nondiscrimination was added. A more substantial revision occurred in 1979, when the social worker’s ethical responsibilities to clients, employers, the profession, and society at large were further clarified. Six broad standards of conduct, which reflected the historic traditions of the profession and remain the foundation of the code, were identified: service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence. This revision also affirmed that the code should serve as a means of enforcing social workers’ adherence to the profession’s ethical standards. Numerous modifications occurred in the 1990s. These included elaborating upon the social worker’s financial obligations to clients and the nature and limits of the professional relationship. The 2008 revision expanded expectations regarding nondiscrimination to include sexual orientation, gender identity, and immigration status. The most recent revision occurred in 2017; the most significant modification involved ethical standards associated with the social worker’s use of technology and social media. All professional social workers are responsible for understanding the expectations spelled out in the Code of Ethics. In its introduction, NASW clarifies that the Code of Ethics is not prescriptive. Rather, it provides social workers with a set of principles to assist them in determining behaviors that are necessary and acceptable for carrying out their professional function, as well as those behaviors that are unacceptable. The code serves a sixfold purpose: 1. Identify core values on which social work’s mission is based. 2. Summarize broad ethical principles that reflect the profession’s core values and establishes a set of specific ethical standards that should be used to guide social work practice.

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3. Help social workers identify relevant considerations when professional obligations conflict or ethical uncertainties arise. 4. Provide ethical standards to which the general public can hold the social work profession accountable. 5. Acquaint practitioners new to the field with social work’s mission, values, ethical principles, and ethical standards. 6. Articulate standards that the social work profession itself can use to assess whether social workers have engaged in unethical conduct. NASW has formal procedures to adjudicate ethics complaints filed against its members. In subscribing to this code, social workers are required to cooperate in its implementation, participate in NASW adjudication proceedings, and abide by any NASW disciplinary rulings or sanctions based on it.

The fact that the code is suggestive rather than prescriptive reflects the realities of social work practice. While social workers are always required to act in accordance with the ethical standards outlined in the code, they also must attend to additional mandates, which at times may lead to competing demands and obligations. The code also serves as a guide for adjudication when the conduct of social workers is alleged to deviate from the profession’s standards. While an international code of ethics for social workers has not been developed, the International Federation of Social Workers has defined a set of principles that closely parallel the NASW code and that pay particular attention to human rights (https://www.ifsw.org/wp-content/uploads/2018/06/13-Ethics -Commission-Consultation-Document-1.pdf). The International Association for the Advancement of Social Work Practice with Groups also has developed ethical standards for this modality that build upon the NASW Code of Ethics (https://www.iaswg.org/standards). The relationship between client and worker is a fiduciary relationship (a relationship of trust), and it offers the client legal protection, including informed consent, confidentiality, and privileged communication (with important limitations discussed later in this chapter). Informed consent protects clients’ rights to self-determination and privacy. Reamer (2013c) identifies six standards that must be met to fulfill the requirements of valid informed consent: 1. 2. 3. 4.

Worker coercion is absent. The client is able to provide informed consent. Consent is specific. Consent forms are clear and understandable.

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5. Clients must feel that they have the right to refuse or withdraw consent. 6. Client decisions must be based on sufficient information.

Exceptions to these standards exist, despite widespread consensus. State statutes, for example, differ on the legal rights of parents to make decisions for their children and how much autonomy children are granted to make decisions for themselves. In some states, an adolescent may provide her own consent to obtain contraception or an abortion, or to enter substance abuse treatment. In other states, parents must be notified, and only they may give consent. The employing organization and the worker, therefore, must know how to acquire informed consent and the limitations of and exceptions to consent. Informed consent is a process that includes furnishing information to clients and partnering with them about assessment and interventions. Informed consent involves much more than simply securing a signature. The profession’s Code of Ethics primarily speaks to traditional social work practice involving face-to-face contacts with clients. Ongoing efforts have been undertaken to adapt ethical guidelines for social workers engaged in online counseling, using technology to enhance their practice, or both, and these are reflected in the 2017 revisions. Frederic Reamer has been a leader in developing appropriate standards (2013a; 2013b; 2015). He has identified several areas of concern: 1. Informed consent. Social workers must take steps to ensure that clients engaged in e-therapy understand the risks and benefits associated with the method. This includes ensuring that the client understands the informed consent agreement itself, since it often is conveyed only in writing. 2. Privacy and confidentiality. The social worker should take precautions to ensure that any information conveyed electronically to or about a client be protected to the fullest extent possible. Since complete confidentiality cannot be guaranteed, given the increasing threat and sophistication of hacking, this should be included in the discussion of informed consent. Clients’ electronic records should be encrypted and protected with strong passwords. Unless there is a compelling reason to do so (for example, a client’s well-being is in question), the social worker should avoid searching for a client online. The social worker should determine in advance with clients how they can be contacted while maintaining confidentiality, since individuals other than the client may hear voice mails and the agency’s phone number and name can be seen on caller ID by anyone in the client’s household. 3. Boundaries and dual relationships. Social workers should avoid using their personal social media accounts to contact or communicate with clients. If the client

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initiates such contact, this should be discouraged. Social workers should consider maintaining two social media sites—one for their professional life and one for their private one. 4. Professional responsibilities. Since e-counseling can occur across state lines, workers must be sure that they understand and adhere to any relevant state legislation. This could include the need to possess a license to practice in the state in which the client lives and to adhere to mandatory reporting guidelines. 5. Records and documentation. Electronic communication provides its own means of documentation. However, if the social worker is engaged in e-counseling, documentation of these contacts is necessary, just as it is in face-to-face interviews.

Social workers inevitably will face contradictory and competing professional obligations that may create ethical conflicts and dilemmas. In some instances, a careful reading of the Code of Ethics will provide resolution of these issues, as the following vignettes reveal. Case Vignettes: Using the Code of Ethics to Resolve Dilemmas

A patient’s family demands that the medical social worker not tell her client that he is terminally ill. When the patient asks her directly what his prognosis is, she feels “stuck.” In this case, the resolution is clear. The social worker’s obligation is to her patient and protecting and promoting his interests. Therefore, she is obligated to answer his question truthfully. The issue becomes not whether she should answer this question honestly, but how to do so in a way that maintains the family’s support of the patient and involvement in his care. The worker must be with both parties—in this case the patient and his family—not with one or the other. We take up this mediating role in subsequent chapters. Take this scenario, for instance: Paul works in a drug treatment program. Many of the clients are court ordered to attend the program as an alternative to incarceration. Agency policy requires the social worker to terminate services to clients if they miss three appointments; this is necessary because the agency operates with a long waiting list. Paul’s client, Phyllis, was ordered to attend the program as one of the conditions of having her children returned to her from foster care. She has missed three out of the last five meetings, with no explanation. Phyllis comes to the clinic without an appointment and tearfully requests that Paul “give her one more chance.” Paul explains that agency policy requires him to terminate services and offers to provide her with

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referral information. He reminds her that this was discussed in their first session, as well as after she missed her first and second appointments.

It might appear that Paul is not acting in the best interests of the client and is putting the agency interests above that of the client. From an ethical perspective, however, Paul’s behavior is appropriate. He met the requirement of informed consent when he explained the agency’s policies regarding termination and reminded Phyllis of this after her absences. He also offers to provide Phyllis with other resources, should she wish to follow up. Paul explains this to her in a compassionate, nonaccusatory way. He understands that Phyllis may not be ready to commit to getting clean despite her stated desire and mandate to do so. He also understands that while she may not be ready now, his handling of the situation could affect whether she reaches out for help later. In subsequent chapters, we explore the skills that the social worker utilizes when clients are ambivalent about or not ready to accept the help we are offering. Ethical Challenges

At first glance, these two scenarios may seem to present the worker with an ethical challenge. In fact, the appropriate course of action is relatively straightforward. We may experience ambivalence, concern, and frustration, but our responsibilities often are clarified in the Code of Ethics. Practice concepts and methods, and even the code, are not always sufficient to resolve ethical issues and value conflicts when they do appear. This reflects the numerous pressures and competing interests that social workers must accommodate in their work. Social work scholars have created guidelines for ethical decision-making to guide us in these instances (Dolgoff, Harrington, & Loewenberg, 2012; Reamer, 2013c). Such guidelines can help social workers identify the ethical dimensions of a practice situation and arrive at a resolution. Dolgoff, Harrington, and Loewenberg (2012) suggest that the first step is to examine the NASW Code of Ethics to determine if any of its principles apply. Since many ethical dilemmas confronted by workers are not directly dealt with by the code, the authors developed an “Ethical Principles Screen” with the following elements: 1. Protection of life. Protecting a client’s life and the lives of others takes precedence over any other professional obligation. A severely diabetic adolescent, for example, refuses lifesaving insulin injections and diet restrictions because they interfere with her quality of life. Using the Ethical Principle Screen, the worker is

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justified in compromising the girl’s privacy because protecting her life is of primary importance. In such situations, the client must be told what is being done and why. Equality and inequality. People have the right to be treated equally, but people with less power and greater vulnerability have the right to be treated differently. In the case of an abused child, the child is not in an equal position relative to the abuser. The worker’s obligation to protect the child is of a higher order than the abuser’s right to privacy and confidentiality. As we discuss later in this chapter, the worker also must comply with relevant legal mandates. Autonomy and freedom. The profession has an unyielding commitment to support and foster a client’s autonomy and freedom. Clients must be able to act in accordance with their own decisions. Others (especially social workers) must respect and support the person’s right to do so. Legal mandates in this area also apply. Least harm. The worker is required to choose the option that results in the least immediate or permanent harm, or else the most easily reversible harm. For example, before a social worker suggests that a client withhold a rent payment to protest dilapidated housing conditions, less risky alternatives should be attempted. Quality of life. The social worker should not ignore a client’s poor quality of life; client and practitioner should work together to improve it to a reasonable degree. Privacy and confidentiality. Social workers must make ethical decisions that fortify every person’s right to privacy. Confidential information must be kept confidential to the extent possible by law. Truthfulness and full disclosure. This demands that social workers speak the truth and fully disclose all significant information to those served.

In making ethical decisions, satisfying the higher-order principle takes precedence over satisfying a lower-order principle. Case Example: Ethics Screen

The client is a 12-year-old sixth grader who is 10 weeks pregnant. The school nurse referred her to the social worker. The youngster said that she does not want an abortion and does not want her parents to know that she is pregnant. The worker confronts an ethical dilemma: respect the child’s wishes for confidentiality, or respect the parents’ right to protect their daughter from potential health risks. In the Ethical Principle Screen, principle 6 states that a social worker should not violate a person’s right to privacy and confidentiality without permission. Ethical principle 3 emphasizes respect for an individual’s right to be self-ruling.

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Table 3.1 Loewenberg and Dolgoff Ethical Principles Screen • The protection of life • Equality and inequality • Autonomy and freedom • Least harm • Quality of life • Privacy and confidentiality • Truthfulness and full disclosure

These principles support honoring the youngster’s decision about her pregnancy and her right to confidentiality. However, since pregnancy poses a potential danger to a 12-year-old (principle 1), the worker is justified in violating the principle of confidentiality and notifying her parents unless state law specifically prohibits this. The social worker must tell the youngster first that her parents must be notified, as required by the code, and, consistent with principle 6, afford her time to tell them herself, either alone or in the company of the social worker. Table 3.1 summarizes considerations associated with an ethics screen. Legal Mandates

Even with the guidance of the code and the ethical principles screen, social workers are often challenged to respect the client’s right to confidentiality and privacy due to legal mandates and the demands of third-party payment and the worker’s employing organization. Social workers must be aware of their legal obligations in five realms: statutory (state and federal) law, constitutional law, regulatory law, court-made and common law, and executive orders (Reamer, 2005). The most significant of these are statutory laws that direct mandated reporting and the duty to warn and protect. All 50 U.S. states have enacted mandatory reporting laws designed to protect vulnerable individuals like children, the developmentally disabled, and the aged. Laws vary by state, but the intent is the same, which is to require social workers and other mental health professionals to report suspicion of abuse and neglect. The social worker is not responsible for determining whether such abuse has occurred; the social worker’s responsibility is to report suspicions to the designated agency. This mandate means that the social worker cannot promise a client blanket confidentiality, even though confidentiality is a cornerstone of the profession’s Code of Ethics.

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In the United States, 34 states require and 14 allow professionals—including social workers—to warn and protect individuals who might be targets of a client’s violence (National Conference of State Legislatures, 2018). Only 4 states do not address this duty to warn. This mandate stems from two different decisions handed down by the California Supreme Court in the 1970s in the Tarasoff v. Regents of the University of California case. In this case, a client of a counselor at the University of California at Berkeley stated his intent to murder an unnamed woman, later identified as Tatiana Tarasoff. The counselor notified campus police, who interviewed the client and warned him to stay away from Tarasoff. Ultimately, the client murdered Tarasoff, and the family sued the university police and the university counseling services. The first decision required professionals to warn potential victims. The second decision expanded this responsibility to include protecting the potential victim from harm (Granich, 2012). The mandates associated with the duty to warn and protect vary by state and include protecting a client from self-harm (Dolgoff, Loewenberg, & Harrington, 2012). Reamer (2016) describes the varied approaches that states have adopted to warn and protect potential victims and suicidal clients. In states that establish a duty to warn or protect, the bar is set high; social workers who fail to discharge their duty expose themselves to considerable risk. In states that establish a privilege to warn or protect, social workers are permitted, but not required, to disclose confidential information without a client’s consent. That said, even in the latter states, social workers must meet the standard of care regarding whether they should have disclosed confidential information to protect a third party from harm (Reamer, 2016). Other major laws that directly affect social workers include the federal Health Insurance Portability and Accountability (HIPPA) act, which was signed into legislation in 1996 and outlines patients’ right to privacy and the protection of medical records—including those of social workers’ clients. While this is a federal regulation, state laws take precedence if they are more stringent. The Family Educational Rights and Privacy Act (FERPA), first enacted in 1974 and amended several times since, is a federal law that protects the privacy of student education records. Any school (and staff that it employs, like social workers) that receives federal money from the U.S. Department of Education must adhere to these privacy standards or risk losing funding. The federal Confidentiality of Alcohol and Drug Abuse Patient Records Act of 1987 recognized the stigma associated with drug addiction and alcoholism and specifically spelled out the privacy rights of clients receiving treatment for substance abuse. Any agency (and its personnel) that receives federal money is subject to these requirements, and like FERPA, risks losing funding for noncompliance with or violation of these rules.

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Each social worker is responsible for knowing the requirements of all relevant federal, state, and local laws. The Code of Ethics does address instances when a client’s privacy must be violated. This includes the requirement that social workers inform the client at the outset of their work of any relevant legal mandates and, if a report must be made, inform the client, preferably in advance, that they are making a report or taking a mandated action. Statutory laws protect social workers from being sued for an ethical violation if the report is made in good faith. Legal and ethical experts strongly recommend that social workers consult colleagues, supervisors, and/or legal counsel to assist them in understanding their legal obligations, balancing these against their ethical obligations to clients (Dolgoff, Harrington, & Loewenberg 2012; Granich, 2012). Reamer (2005) recommends that a social worker engage in the following steps when determining what course of action to take: 1. Identify conflicts between ethical obligations and legal requirements. 2. Identify individuals, groups, and organizations that will be affected by the worker’s decision. 3. Identify all courses of action, the participants involved in each, and the possible risks and benefits of each. 4. Examine the reasons for and against each course of action, taking into account relevant ethical principles, legal statutes, and personal values. 5. Consult with colleagues and experts. 6. Make the decision and document the decision-making process. 7. Monitor and evaluate the decision.

Case Example: Mandatory Reporting

Research clearly demonstrates that babies born to women who have abused drugs and alcohol during their pregnancy face numerous health risks and developmental challenges. Patricia works in an inner-city health clinic. She provides supportive individual and group work services to pregnant women. Her client, Tanya, age 20, has been a drug addict for at least 10 years. Her drug of choice is heroin. Tanya discloses to Patricia that she has just learned that she is pregnant, and she is looking forward to having a baby, hoping that this will help her kick the habit. Were it not for mandatory reporting laws, the worker’s actions would be clear, even if they might be distressing to them. Tanya’s right to privacy would prevent Patricia from reporting this information to child welfare authorities or law enforcement.

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However, as of 2015, 47 states and the District of Columbia address drug use of parents in their reporting statutes. In most instances, the statutes focus on children’s exposure to illegal drug activity and/or a child’s prenatal exposure to drugs through the mother’s drug use after the child is born (https://www.child welfare.gov/pubPDFs/drugexposed.pdf). A total of 15 states require healthcare workers, including social workers, to report a pregnant women’s substance abuse as a requirement of mandatory reporting laws related to child abuse (https://projects.propublica.org/graphics/maternity-drug-policies-by-state). Patricia’s actions must be consistent with relevant state laws. If, for example, Patricia worked in one of the 15 states, she would be required to report her client’s drug abuse to the appropriate authorities. According to the Code of Ethics, the worker does not have to ask the client for permission to report, but she or he is required to inform the client that a report must be made, preferably before this action is taken. Privileged Communication

Except for mandatory reporting requirements, social workers typically are prohibited from revealing confidential information. Thus, there is a legal mandate to protect the client’s privacy. Privileged communication is a legal exemption that limits the government’s right to force a social worker to break confidentiality. The client’s right to confidentiality is an ethical principle, but its violation by a social worker can result in a lawsuit. In MacDonald v. Clinger, a psychotherapist divulged personal information to a patient’s wife. The court ruled that this was a breach of confidentiality and allowed the patient to sue for damages. Violations of confidentiality can result in civil but not criminal charges against the social worker. In Jaffee v Redmond (1996), the Supreme Court had to decide whether the conversations between social workers and their clients were privileged and protected from civil complaint in federal court (Lens, 2000). Jaffee administered the estate of a person who was killed by a policewoman, Redmond. Jaffee filed suit in federal court that Redmond had used excessive force. Jaffee learned that Redmond went into counseling with a social worker after the event and sought the notes from their 50 counseling sessions. Redmond and the social worker argued that session notes were covered as privileged communication. A lower court ruled in favor of Jaffee. In accepting the case on appeal, the Supreme Court ultimately determined that privileged communication was essential to protecting the mental health of the community and “outweighed the evidentiary needs of the court” (Lens, 2000, p. 274).

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The Supreme Court also decided that social workers are in fact covered by the protection of privileged communication, representing a major victory for the social work profession. In civil proceedings, clients can be assured that confidentiality “stands on the same ground as the confidentiality between a lawyer and her client and a husband and wife” (Lens, 2000, p. 275). Case Example: Privileged Communication

A social work student was placed in a day program for adults with developmental disabilities. She was working with Paul, 26, who had mild developmental disability and significant cognitive delays. Paul also was HIV-positive. June’s work with Paul focused on helping him develop social skills that would allow him to become more independent, as well as to deal with life stressors. He continued to live at home with his parents. Paul disclosed to June that he was having sexual relations with a young woman that he referred to as his “girlfriend.” When June brought up the need for “safe sex” practices and the risk that he posed to his girlfriend because of his diagnosis, Paul did not appear to understand. Alarmed, June consulted with her field instructor, believing that she had a duty to warn the young woman and wondering to whom she should report Paul’s actions. June was dismayed to learn that she could not report Paul’s actions because this would violate Paul’s right to privacy and was a breach of confidentiality. June then suggested that she tell Paul’s parents about his relationship, since they “take care” of him. This also was prohibited; his parents care for him but are not his legal guardians. June’s field instructor helped her develop a strategy to educate Paul about safe sex practices and also helped June deal with her feelings about her inability to “protect” Paul’s girlfriend. The state in which this incident took place does not include a diagnosis of AIDS in its “duty to warn” statute. In fact, people living with AIDS are legally defined as a “protected class” in the state. Criminal statutes in the state, however, have been used to prosecute individuals living with AIDS who have knowingly and deliberately infected another individual with the virus. Health facilities and labs also are required to report to the appropriate state health authorities the names of anyone who is newly diagnosed. We use this example for three reasons. First, it underscores how critical it is for social workers to be knowledgeable about state laws regarding duty to warn and protect. Second, it reminds us that clients may engage in criminal behavior, but this alone does not justify violating their right to privacy. Third, the example highlights how laws reflect public perceptions, regardless of accuracy. When the AIDS epidemic first surfaced in the 1980s, the public’s response led

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to the victimization and stigmatization of those infected with the virus. Early legislation variously sought to penalize or protect individuals living with AIDS, depending upon the sentiments of the public and legislators. Since this time, and because so much more is now known about AIDS and its causes, legislation has evolved, and while some states do have criminal statutes, most have laws to protect individuals living with AIDS from discrimination and uphold their right to privacy (http://www.hivlawandpolicy.org/). To date, no state includes a diagnosis of AIDS in its mandatory reporting guidelines. Boundary Violations

Boundary violations represent some of the most difficult situations in which social workers may find themselves and can represent serious professional ethical misconduct. A boundary violation means that the social worker’s behavior has “crossed a line” in some way in the relationship with a client. A sexual relationship with a client is the most blatant such example (Reamer, 2015). Though rare, sexual misconduct represents the largest number of complaints filed with NASW against a social worker (Reamer, 2015). The Code of Ethics prohibits social workers from having sexual contact with clients at any time (before, during, or after a professional relationship). Many states also have passed laws imposing criminal penalties for such transgressions. A sexual relationship may be the most egregious example of a boundary violation, but there are many other examples that are much more common and, in some cases, much harder to recognize. For example, a social worker should not hire a client to babysit or to mow the lawn. These may seem like relatively benign arrangements. However, they transform the worker/client relationship into an employer/employee one. What happens if the client were to discipline the worker’s child in a way of which the worker disapproves? Suppose that the client did not approve of how the worker treats their children? What if the client accidentally cut down a prized plant while cutting the grass? Social workers may consider allowing clients to pay them using services rather than money, in cases where clients have limited or no financial resources. However, bartering for professional services is unethical, even if the reasons might be principled. While dual relationships that cross boundaries have the potential to create tensions and should be avoided in certain agency contexts and situations, they sometimes may be helpful. For example, the authors have attended clients’ graduations, exchanged symbolic termination gifts, and attended funerals of clients and/or clients’ loved ones. When making home visits, we have always accepted an offered cup of coffee or a bite to eat; to reject these gracious offers would

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be perceived by the client as a slight. There is a difference between boundary violations and crossings (Reamer, 2015). Dual relationships that are, or have the potential to be, exploitative or coercive represent a serious ethical breach. Boundary crossings are a loosening of professional limits that may foster and promote the working relationship. Judicious boundary crossings that are in the clients’ interests cannot be ruled out. Case Illustrations: Boundary Violations and Crossings

When one of the authors started out as a professional social worker, she worked at a large public high school in the inner city. Concerned teachers and administrators referred clients because of disruptive behavior in the classroom. In many instances, the adolescents’ behavior reflected the difficult, often traumatic, and painful circumstances that they faced in their homes and neighborhoods. The students’ behavior was often a desperate cry for help, and the author responded by giving out her home phone number. This quickly led to late-night, teary calls in which clients voiced their pain and unhappiness, which left the author feeling helpless and worried. The author also quickly became overwhelmed and angry. The anger initially was directed at the clients, but, with the help of her supervisor, she realized that she was angry with herself for not setting appropriate boundaries. The supervisor encouraged the author to develop a plan to talk to each of her clients and explain her role and how she could be helpful, as well as why it had been unwise for her to give out her number. As social workers, it is our job to help clients be more successful and effective in their transactions with their environments. When we are so available to them, this undermines their ability to do this. Also, it is much more difficult to tighten loose boundaries than it is to loosen boundaries that have already been established. A social work student was placed in an inpatient psychiatric facility located close to her home. Pamela and her field instructor were helping the client, Jeff, transition back into the community. This involved linking him to various resources, one of which was an Alcoholics Anonymous (AA) group. Pamela herself was in recovery, though she had not mentioned this to Jeff or her field instructor. She attended her “home group” meeting (the group that AA members consider their primary source of support) and discovered that Jeff was in attendance. She learned afterward that her field instructor had arranged for him to attend this particular meeting because it was close to the psychiatric facility, as well as to where Jeff would be living upon discharge. While this was nothing more than coincidence, it represents a classic example of a boundary violation.

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Pamela was unsure what to do when she saw Jeff. She could tell that he was uncomfortable, as was she. She said hello to him but did not contribute to the meeting, given her discomfort. Jeff also did not contribute, other than to introduce himself. After talking with her field instructor, Pamela decided to talk directly with Jeff about what had happened and his reactions to seeing her there. She also decided to find another home group, since it was in Jeff ’s best interest for him to continue at this group, given its convenience. Pamela readily understood that they both could not attend the same group; she also acknowledged that neither she nor Jeff would be unable to use the support and assistance of the group so long as they both were there. The social worker worked in an agency located in a small town. One of her clients called to say that she would be unable to attend their session, as her car had to go into the shop for repairs. The client had limited income, so she did not have the funds to take a taxi from the auto repair shop to the worker’s agency. Though the shop was not far from the agency, it was raining hard, and the client, age 60, had some problems that made walking difficult. The worker offered to pick the client up at the repair shop and bring her to the agency, since it was close by. There was minimal risk to the client or worker in this situation, other than the possibility of a car accident (for which the social worker had insurance). The worker and client had been working together for some time, and both had a clear sense of the boundaries of their professional relationship. The worker did have some concerns about how the client would get home after the session, since she did not believe it would be appropriate for her to give the client money for a taxi (and she had other clients to see). She shared this concern with the client before picking her up at the repair shop, and the client assured her that she could find a way home. As it turned out, the worker secured agency funds to pay for the client’s return home, which allowed her to help the client without crossing any boundaries The Social Worker’s Personal Values

We must consider our own values and ethics in relation to those whom we serve: our clients, the profession, the agency, and society. The literature on professional ethics in social work has focused primarily on decision-making rather than on the values and ethics of the worker. Social workers must develop self-awareness about their personal ethical and value standards and recognize instances of “values incongruence” when their personal beliefs conflict with their professional

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responsibilities (Chechak, 2015). Research findings suggest that the ethical dilemmas that social workers face often result from this incongruence and have the potential to undermine their effectiveness (Winter, Kattari, Begun, & McKay, 2016). Findings also suggest that when conflicts arise, professional values take precedence (Valutis, Rubin, & Bell, 2014). This requires that social workers become aware of and acknowledge their personal values and beliefs (Spano & Koenig, 2007). Spano and Koenig (2007) identify a six-step process that social workers may need to follow to reconcile instances of value incongruence: 1. Self-awareness. Become aware of one’s personal worldview and the values that it reflects. 2. Self-reflection. Consider the implications that one’s personal values have for professional conduct and practice. 3. Understanding and applying the Code of Ethics. Understand the NASW Code of Ethics and appreciate its relevance and necessity in social work practice. 4. Comparing personal worldview with professional responsibilities. Identify discrepancies between one’s worldview and professional obligations. 5. Professional decision-making. Decide upon a course of action that reflects the Code of Ethics. 6. Professional ethical action. Take action that is consistent with the Code of Ethics.

We should not ignore or discount our values. All of us are entitled to our beliefs. However, we must work actively to reconcile them with what is demanded of us as social workers. Our conscience is an integral part of who we are as people (Adams, 2011). Case Illustration: Values Incongruence

Simone facilitates a support group for mothers living in a homeless shelter. The group provides support to the women, most of whom have experienced domestic violence, childhood abuse, and problems with substance abuse. Group participation also assists members with identifying resources they need to improve their circumstances and motivating them to persist in these efforts. Most of the women have several children, typically by different men. In many instances, the fathers are imprisoned or in some other way unavailable to assist with their children’s care. In one session, members are celebrating the news that Tamara, the mother of two young children, is pregnant. Simone finds herself losing patience with the members and has a hard time understanding why the news was cause

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for celebration. She refrains from saying anything to the group, but she discusses her reactions with her supervisor. She acknowledges that she thinks that Tamara, as well as other members, are “irresponsible” and “should know better” than to continue getting pregnant. Her supervisor assures her that such feelings are understandable, that it is easy, when you “are on the outside looking in,” to condemn others for their actions. Students may read this and experience anger or dismay at Simone’s reactions. The authors do not. In fact, we credit Simone for her honesty with herself and with her field instructor, and we credit her field instructor for normalizing Simone’s feelings and encouraging her student to be forthcoming. Simone—like all of us—will be unable to keep her personal values from intruding into her work if she is unable to acknowledge them. The issue for each of us is not what we believe, feel, and think, but rather what we do with these personal reactions that matters. Readers may have assumed—correctly—that the members of this group are women of color. Readers also may have assumed that Simone is white. But that is incorrect—she identifies as African American. Simone’s racial similarity to the group members does not mean that her personal values and beliefs are the same. In the next chapter, we discuss cultural competence and sensitivity to diversity, which includes understanding how assumed cultural differences and similarities may affect the working relationship. The issues raised in this example will be revisited throughout this book. How do we respond when our clients’ actions conflict with our beliefs? Can we encourage clients to engage in more responsible behavior? How do we help clients engage in behavior that is more helpful to them? For now, we want to encourage readers to begin to think about being in the world of “is” rather than the world of “should.”1 The world of should is the world that we think is best for our clients. It is based upon our beliefs about right and wrong and good and bad. It is not necessarily a “bad” vision for our clients, but it reflects what we want, not necessarily what they want. The world of is is the one that is inhabited by our clients. It reflects their social reality, their perspectives, and their lived experiences. And it is this world that we must respect and enter. Integrated Modalities, Methods, and Skills

Life-modeled social work practice consists of six modalities: work with individuals, families, groups, and communities, organizational intervention, and legislative advocacy and politics. Contemporary practitioners must be equipped to work effectively within all six modalities, moving readily and skillfully from one

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to another as situations require. In some instances, we work in partnership with our clients to improve their interactions with the systems that matter to them. In others, we work to enhance the responsiveness of social institutions to improve the well-being of all, particularly those who are most vulnerable. And in still others, we engage in both sets of activities. Some methods and skills are common to all modalities, while others are specific to one or two. Commonly held methods and skills are used for developing explicit agreements and exploring client concerns. Specific methods and skills are used to form groups, develop mutual aid, and deal with internal group obstacles; help families deal with maladaptive communication and relationships processes; help communities and neighborhoods acquire needed resources and improve the quality of life for, and cohesiveness among, residents; influence organizational policies and create needed programs and services; and engage in legislative activity. Practitioner style and creativity are indispensable in life-modeled practice. Clients need social workers who are willing to reveal their humanness, vulnerability, and spontaneity. Clients do not expect social workers to be models of perfection and virtue. A practitioner’s empathy, commitment, and desire to be helpful speak louder than any possible awkwardness or mistake. Successful practitioners are “dependably real” rather than “rigidly consistent” (Rogers, 1961, p. 50). Professional education and socialization can stiffen practice and discourage purposeful and spontaneous reactions like humor. Yet, used appropriately, humor can relieve a client’s (and the worker’s) tensions, anxiety, and embarrassment. For instance, after heart surgery, a hospital patient was very anxious about possibly being impotent. He had been unable to discuss his concern with his physicians. The social worker noted an awkward silence between them and “tuned in” to what it might mean. The worker gently asked, with a smile, “Are you worried about whether the lead has run out of your pencil?” He responded with laughter, and a frank discussion followed (Gitterman, 2003a). Relationship Between Client and Worker

In life-modeled practice, the professional relationship is conceived as a humanistic and client-centered partnership, with power differences between the partners reduced to the greatest degree possible. The relationship between client and worker shifts from subordinate recipient and superior expert to a relationship characterized by mutuality and reciprocity. Social workers bring professional knowledge and skill to the therapeutic encounter. Clients bring knowledge of

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their life issues and their life stories and are responsible for work on their goals and tasks. Social workers are responsible for creating conditions that will facilitate this work. To be effective, the relationship also must be rooted in empathy. Absence of empathy inevitably leads to therapeutic errors and failures, as well as to client dropout. The capacity for empathy is relative rather than absolute. Some people may be empathically attuned to certain feelings but not to others—to sadness but not to anger, to pride but not to shame. With practice experience, however, social workers’ ability to empathize will increase. However, if one cannot empathize with certain people or their feelings, this limitation must be recognized. The more we learn to be in the world of “is,” not “should,” the more we are to understand our clients’ social reality and empathize with them and their struggles. Inexperience, together with lack of empathy, may occasionally lead to underestimating people’s strengths and their potential for growth. This is especially true in settings that serve clients facing overwhelming challenges. A beginning social work student reports on how her low expectations were turned around: My client [in a day treatment program for those living with chronic schizophrenia] was riding with me in the program’s van. The driver stopped the van and asked my client to go across the street to buy a pack of cigarettes. I began to argue that Matthew does not speak, cannot make change, and doesn’t know how to cross the street. The driver said, “Gee, I didn’t know that. If I had, I wouldn’t have asked him, but he’s been getting my cigarettes for me for weeks now.” I think I had been seeing my clients as bundles of symptoms rather than as living, growing human beings. Our driver didn’t know about the “hopelessness” of the symptoms and therefore he set his expectations higher and more accurately than mine. This was an important lesson for me.

When our clients trust that we understand and respect their worldview and are concerned with their well-being, they are better able to take advantage of our offer of assistance. Without this basic trust, clients may go through the motions of accepting help without really doing anything differently. However, creating a working alliance with clients is not enough to ensure that our work with clients will be helpful. The working relationship and the trust that it reflects are the means through which clients become more adept in their transactions with their environments. In many practice settings, workers have little time to devote to creating a working relationship. Their initial encounters with clients—in some cases in the first couple of minutes—becomes critical for establishing the trust, even if it is tentative, that is the foundation of the working relationship.

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Case Example: Establishing Trust

A social work student, Linda, works in the victim assistance program within the office of the state’s attorney in a large urban jurisdiction. Linda is a young white woman, while most of her clients are African American or Latina/Latino. She works with victims of domestic violence when the cases against their perpetrators go before the court. The program is understaffed and underfunded, which results in Linda having only a brief encounter with victims. In most cases, she sees the victim for 15 minutes before the trial. Linda’s job is to familiarize the victim with the legal process and affirm the victim’s account of what happened. She also serves as a broker, providing the victim with recommendations for resources. In many instances, victims are reluctant to follow through with their original complaint of domestic violence; reasons include fear of the perpetrator, loyalty to them, dependence on the perpetrator, and suspicion about the justice system. In her first and only contact with her clients, Linda must deal with the possible barriers to engagement that may be present, most notably their suspicion of her and the “system” and their ambivalence or unwillingness to testify against their abusers. She does this by anticipating reactions that her clients may have and putting these feelings into words—particularly those that reflect negative feelings about her. In chapter six, we discuss these and other skills that facilitate engagement. With some clients, particularly children and adolescents, and those who have experienced some form of trauma, particularly in childhood, establishing a working relationship is part of the work. Individuals who have problems with attachment view relationships with suspicion, fear, and mistrust (Corbin, 2007; Nelson & Bennett, 2008). Case Example: Working with Attachment Challenges

Victimization in childhood often leads individuals to avoid relationships— attachments—to others. They have learned that relationships are a source of pain rather than comfort. They may avoid relationships altogether or may need and seek out excessively close connections to others. In both instances, these relationships are superficial, since the individual lacks the capacity to form genuine connections to others (Goldsmith, 2010). Clients with attachment issues will be reluctant to engage with the social worker. Therefore, the worker’s initial interactions will need to foster comfort, safety, and security simultaneous to developing a plan to address the difficulties that require social work intervention.

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Jerome started his field practicum a month ago at a residential treatment facility for children. He is assigned by his field instructor to work with a new resident, Billy, age 9. Placement in the group home was necessary because of the client’s failure to adapt to placement in a foster home. Billy was initially removed from his biological mother due to severe physical abuse, and he has been in three prior foster placements. As defined by the facility, Jerome’s role will be to help Billy successfully transition into the facility and help him connect to his peers and staff. His field instructor suggests that for his first contact with Billy, Jerome take him to the playground and “shoot some hoops” or play some other kind of game with him. Jerome expresses confusion, wondering how “playing” is social work. Like many students new to social work, Jerome fails to appreciate that Billy will have a hard time connecting with him due to his history of abuse, rejection, and abandonment. Play is a nonthreatening way for Jerome to engage Billy and discuss the purpose of their working together. Developing a relationship with Jerome provides Billy with the tools he needs to establish healthy relationships in the future. In chapter seven, we discuss ways in which we can work with clients who have a hard time engaging with the social worker. Research Application: Attachment Issues of Children in Foster Care

The findings of numerous studies reveal the problems that children and adolescents in foster care have with developing relationships with others, including those who are there to help them (Shemmings, 2015). This research provides guidance for social workers in child welfare settings, as follows: 1. Social workers must help children cope with the initial trauma that warranted their removal from their families, as well as the trauma associated with the removal itself (Jones & Morris, 2012). 2. Foster children often have great difficulty forming a relationship with social workers (Miller, 2011). 3. The workers must focus on creating a relationship with the foster children that provides safety, predictability, consistency, and nurturing (Carr & Rockett, 2017). 4. Social workers, themselves, are at risk of experiencing burnout and feelings of anger and frustration (because their clients are difficult to engage), sadness and guilt (at their inability to be helpful and “fix” their clients’ problems), or both (Shea, 2015).

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5. The workers’ need to help significant others like foster and biological parents, extended family members, and teachers understand foster children’s needs and behaviors and develop positive relationships with these children also has been documented (Carnochan, Moore, & Austin, 2013).

Ongoing Agreement and Assessment

In life-modeled practice, the social worker and client are partners as they work together throughout their relationship. When the worker-client relationship is clearly defined and mutually agreed upon, client ambivalence is lessened. Shared Definition of Life Stressors and Focus of Work

All helping in life-modeled practice rests on shared definitions of life stressors and explicit agreements on purpose, foci, priorities, selection of modality, next steps, and other arrangements of the work. A client’s desire for assistance, an agency’s offer of service, or a mandated service do not represent agreement until the worker and client reach a shared, specific, and clear understanding about their foci and methods. Reaching agreement is a critical aspect of the initial phase of social work practice and continues throughout the ongoing and ending phases. Agreement between the worker and client protects the client’s individuality, enhances self-direction, and strengthens coping skills. Most important, arriving at an agreement structures and focuses the work, decreases the anxiety associated with the fear of the unknown and the ambiguity inherent in beginnings, and mobilizes energy to direct toward the work. It also reduces some of the power discrepancy between the client and worker at a time when the client is vulnerable to manipulation or misuse at the hands of the agency or professional authority. Assessment

Client participation in continuous assessment ensures shared focus and direction. Life-modeled practice emphasizes assessment of the perceived level of fit between human needs and personal and environmental resources. Professional assessment takes place at every moment in the helping encounter, as well as after each session. Collecting, organizing, and interpreting data are the major assessment tasks associated with assessing the level of fit. Conceptualizing life

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issues and stressors as difficult life transitions and traumatic life events, environmental pressures, and maladaptive family and group processes provides a framework for collecting, organizing, and interpreting data. Clients’ Social and Physical Environment

A social network provides individuals, families, groups, and communities with needed support to deal with stressors. Stress is created when social networks are unresponsive, nonexistent, or characterized by interpersonal conflict. Social inequality based upon race, ethnicity, and religion; income; gender and sexual identity; age; and disability results in restricted access to social institutions and structures, creating stress. Organizations potentially provide essential, life-sustaining resources. They can create stress when policies and procedures are harsh and unresponsive or when services are difficult to access. Physical habitats should support adaptedness, well-being, and growth. They become life stressors when they fail to provide affordable and safe housing and space for recreation and sufficient protection from crime. The physical environment also may be a source of stress due to pollution, aging infrastructures that result in exposure to toxins, and other environmental hazards.

FOUR PHASES OF LIFE-MODELED PRACTICE

The four phases of helping—preparatory, initial, ongoing, and ending— constitute the processes and operations of life-modeled practice. These processes ebb and flow in response to the interplay of client characteristics, needs, and goals, worker assessment, agency function, and environmental forces. We present the phases separately to make it easier for readers to understand the methods and skills associated with each. In practice, many skills are relevant in more than one phase. In addition, our work often does not progress neatly and sequentially from one phase to the next. Our work with clients may take a few steps forward and then a few steps back. It may take an unexpected turn in a new direction based upon new information or developments. Further, in many practice settings, our work will take place in one session. In these cases, all phases of work will occur in one session and might be almost indistinguishable from one another. We briefly summarize the four phases next. Subsequent chapters elaborate on each one, as well as on methods and skills that are unique to the client groups: individuals, families, groups, and communities.

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Preparatory Phase: Anticipatory Empathy

Even before the first session, social workers need to prepare themselves to enter clients’ lives by reflecting on available information concerning the probable objective situation, its possible cultural meaning, and its potential impact on the first session. Practitioners also need to reflect on a client’s subjective reality by empathizing with possible perceptions and feelings. Drawing on such anticipatory processes readies the social worker to hear both the more obvious and the more subtle content. Social workers demonstrate empathy by showing interest and concern through nonverbal and verbal means and paying close attention to clients’ verbal and nonverbal communication. While demonstrating empathy is always important, it is essential with mandated and/or ambivalent, confused, and anxious clients. Empathy requires us to enter the world of “is” that we discussed previously. Many clients should want our help, but they don’t. The challenge to us is be curious about hesitation or ambivalence and to see the situation as the client sees it. The first step is to understand that often, from clients’ perspective, the problem is not with them or their lives, but with those who have required them to seek our help. Engaging in anticipatory empathy, demonstrating empathy toward clients, and conveying in verbal and nonverbal ways our understanding based upon this are essential to practice with all modalities. Initial Phase: Getting Started

The client and worker must first identify and define life stressors, since how these are defined largely governs what will be done about them. For some people, multiple stressors lead to disorganization, as with the Williams family described earlier in this chapter. Sometimes work on one life stressor supports coping with others. At other times, the worker and client may need to prioritize the stressors and work on them one by one. Frequently, this work is simultaneously directed toward relieving two or more stressors. Life stressors are the reason that clients seek, are offered, or are required to receive our assistance. Degree of Choice

The initial phase is strongly influenced by the degree of choice about the service. People usually seek professional help and take on the client role when stressors become unmanageable. They are propelled into social work services either out

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of their own quest for help or out of the concern of other people or organizations that then initiate referral. When services are sought, finding common ground between client’s and practitioner’s definitions of the life stressors and hoped-for outcomes and the agency services is usually easier to achieve than when client choice is more constricted. Even under these circumstances, clients may possess a degree of ambivalence about seeking help due to, among other things, cultural values, misconceptions about the nature of social work services, and the sensitive nature of their difficulties. When services are offered to preselected groups or populations, as in outreach programs, the social worker must maintain an ethical balance between active presentation of anticipated benefits and people’s right to refuse service. By identifying and relating to people’s perceptions and definitions of their needs, practitioners are more likely to engage them in the offer of service. When a court order or other institutions and their representatives mandate services, the practitioner must acknowledge the mandate and directly deal with its implications. Both the nature of the mandate and the extent of possible sanctions on violations must be specified. Efforts to locate and respond to people’s discomfort with mandated services are critical. Ongoing Phase: Working Toward Common Tasks

Strengthening and supporting person-environment transactions that enhance the level of fit and personal coping skills and enhance environmental resources required for managing life stressors are central in the ongoing phase. Social Work Methods and Skills

In helping people with stressful life transitions and environmental pressures, supporting and strengthening people’s adaptive capacities and problem-solving abilities can be achieved through the methods of enabling, exploring, mobilizing, guiding, and facilitating. Enabling skills mobilize or strengthen clients’ motivation to deal with the difficult life stressors and the associated stress it arouses. Exploring and clarifying skills provide focus and direction to the work. These skills ensure that we develop an accurate understanding of our clients’ circumstances and what they would like to accomplish. In other words, they help us to “be on the same page” as our clients. Exploring and clarifying skills deepen the working alliance between worker and client. Mobilizing skills strengthen the client’s motivation to deal with difficult life stressors and manage feelings of hopelessness and powerlessness that can

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undermine efforts to change. Clients often need help identifying and building upon strengths and positive attributes within themselves and their environment. These skills enhance motivation and provide clients with hope that change is possible. Guiding skills help clients develop the problem-solving skills needed for coping with life stressors. Skillful guidance depends on the worker understanding the client’s unique learning style, as well as providing opportunities for the client to succeed in change efforts, modeling, and role-play, as well as discussion and exchange of ideas. Facilitating skills encourage clients to remain committed to the work. Many clients are reluctant to examine and work on difficult issues; this includes those who have willingly sought our services. Avoidance may be indicated by passive actions such as withdrawal or overcompliance, nonpassive actions such as interruption or monopolizing, or flight behaviors such as changing the subject and minimizing concerns. If avoidance persists, the worker supportively demands purposive work by commenting on the avoidance pattern, challenging illusions of mutual agreement, and remarking on discrepant messages. These interventions can stimulate and mobilize clients’ energy for the work. On the other hand, they may increase defensiveness or lead to the client dropping out if an underlying working alliance, characterized by the trust described earlier, is lacking. Life-modeled practice always includes an assessment of and work within clients’ social environments. Life stressors emerge from and are resolved through clients’ interactions with their environments. Methods for this type of social work include five sets of skills. Coordinating skills assist both the worker and client with deciding upon and pursing a plan for the work. They include monitoring clients’ progress and the quality of the working alliance to ensure that it is supporting clients’ work, and, when necessary, adjusting the working agreement. They also include connecting clients with needed resources in the external environment and ensuring that they can access them. When clients are unsuccessful in their interactions with their environment, the worker mediates between the client and the people and systems that matter to them. The worker attempts to establish a bridge and identify points of commonality between the clients and the social environments. This involves assisting both sides to negotiate and compromise and requires that the worker see all points of view. Sometimes mediation is not enough to improve communication and relationship patterns between clients and their social environments. Advocacy skills may then come into play. These can involve teaching clients to advocate for themselves, but the worker often is required to advocate on behalf of her or his

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clients’ interests. Advocacy may or may not require an adversarial stance. Workers must assess what strategies are most likely to be persuasive, as well as gauge the potential risks to both themselves and their clients associated with advocacy efforts. Ethical practice may require that the worker adopt a more adversarial position when essential entitlements are denied or client rights are violated, regardless of the risks. Social workers quickly learn that clients’ needs often exceed the environments’ ability to respond. Through innovating skills the social worker fills gaps in services and resources and helps establish preventive and growth-promoting programs. This may involve organizing and mobilizing individuals to collectively address common life stressors, interests, or tasks. Innovation may lead to the need for influencing skills. Targets of these efforts to promote social justice include organizational practices, legislation on social policies, and regulations at local, state, and national levels. In responding to difficult life transitions and harsh environments, families, groups, and communities can encounter interpersonal obstacles such as maladaptive behaviors, conflicted relationships, and blocked communication. Withdrawal, factions, alliances, and scapegoating are examples of dysfunctional patterns in groups. Maladaptive patterns in families include misuse of power and authority, violence, neglect, and child abuse. Maladaptive patterns in communities include unfair allotment of scarce resources, intergroup hostilities, and power structures that exclude vulnerable residents. Helping groups, families, and communities to change these and other maladaptive patterns presents a critical arena for preventive and restorative interventions. The social worker helps members to recognize obstacles, learn to communicate more openly and directly, and attain greater mutuality, trust, and concern for collective well-being. Internal mediating and advocating skills include identifying and commenting on dysfunctional patterns, challenging collective resistance, inviting and exploring conflicting ideas, establishing protective ground rules, lending support, and crediting work. The Ending Phase: Bringing the Shared Work and the Relationship to a Close

Clients and workers often experience phases of termination, including avoidance, negative feelings, sadness, and release. Avoidance is a conscious effort to ward off pain or loss; denial is an unconscious defense against pain or loss. With the worker’s help, clients can begin to relax the avoidance effort and allow feelings of anger and sadness to surface. As the reality of ending is directly confronted, both the client and social worker are free to experience their positive feelings and

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their shared sadness at ending. Not all clients will feel sad; some will feel relieved, neutral, or even cheated. Workers must be careful to avoid forcing an expression of feelings that may not exist. The social worker also helps clients evaluate gains and consider whether some work is still to be done, develop plans for the future such as transfer or referral, and say goodbye and disengage. Endings often occur abruptly, unexpectedly, and without warning. Clients stop coming without explanation, or unforeseen circumstances require them to terminate; or the social worker becomes ill or is suddenly transferred. In these instances, the deliberative process outlined here is not applicable. To the greatest extent possible, however, the worker still attempts to address feelings about ending and the circumstances that precipitate this, as well as identify any gains made and future directions for the client.

Culturally Competent and

FOUR

Diversity-Sensitive Practice and Cultural Humility

Cultural factors are significant features of individuals’, families’, groups’, and communities’ social niche and social time, and influence how they view themselves and their place within their social environments. An essential element of life-modeled practice is respecting clients’ cultural identity. Cultural competence begins with an understanding of the values, traditions, social realities, and challenges of individuals with a shared cultural identity. Sensitivity to diversity expands this understanding to include appreciating the social realities and resulting internalized identities of individuals who possess certain traits or characteristics. Cultural competence and sensitivity to diversity require a high level of self-awareness on the part of social workers, since many of our personal values reflect our cultural identity and social reality. The combination of specialized knowledge and self-awareness ensures that our interactions with clients are sensitive to the objective ways in which we differ from and are similar to our clients and our and our clients’ subjective experience of these differences and similarities and their meaning.

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THE MEANING OF CULTURAL COMPETENCE AND SENSITIVITY TO DIVERSITY

The formal education of social workers usually includes information about specific groups based upon such elements as race and ethnicity. We are not opposed to this approach, but we believe that it is limiting and does not adequately prepare students for diversity-sensitive and culturally competent practice. Acquiring knowledge about a group of people who share certain characteristics ignores the diversity within the group and unintentionally fosters generalizations and stereotypes about the entire group. This approach oversimplifies the role that culture plays in our clients’ lives since many individuals fit within more than one cultural group, a phenomenon known as intersectionality (Jani, Pierce, Ortiz, & Sowbel, 2011; Lum, 2010). It also ignores the realities of numerous other marginalized groups that are not linked by culture, but rather by a similar trait like disability, illness, or age. Our challenge is to understand the social reality of the specific clients with whom we interact, based upon their lived experiences, not upon generalities that may have little to no relevance for them. “Meeting clients where they are” is most critical. This common expression, straightforward as it may sound, lies at the heart of culturally competent and diversity-sensitive practice. It means understanding clients’ social reality: how they view the world that they inhabit and how, in their opinion, that world views them. These two considerations influence how clients perceive us and our offer of assistance, and in turn, their ability to engage with us in a working relationship. Cultural competence and sensitivity to diversity also depend upon us understanding our social reality and our worldview and how it shapes our experiences with our clients. In the sections that follow in this chapter, we present common characteristics of groups of individuals that social workers may encounter in practice. This discussion is by no means exhaustive or comprehensive, but it will assist readers in understanding the worldviews and social realities of many, but not all, of the individuals who identify with or are part of these groups. We start with race, ethnicity, and religion and focus on the common beliefs, traditions, and worldviews of each group. We then turn our attention to gender and sexual orientation, where we examine the impact of external expectations and assumptions on a person’s internalized sense of identity. Finally, we examine age, illness, and disability, focusing on stigma and how it shapes identity and social reality.

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Cultural sensitivity is not an end state that is ever fully achieved. It is an ongoing process in which social workers are continually engaged (Azzopardi & McNeill, 2016). Borrowing from the work of Sue, Nadal, Capodilupo, Lin, Torino, and Rivera (2008) and Sue, Rasheed, and Rasheed (2015), this process consists of three steps: 1. Actively seek to understand our clients’ cultural and social identities and their social reality. 2. Actively seek to understand our cultural and social identity and how they affect our social reality and our work with and understanding of our clients. 3. Actively seek out opportunities to engage with diverse groups.

Acquiring an academic understanding of cultural traditions, beliefs, values, and social realities of groups of individuals with shared identities and traits has merit, despite the limitations we noted previously. Prior knowledge can sensitize us to a client’s experience, but we can never lose sight of the fact that we must be open to the client’s personal narrative. “Rather than focusing on knowledge of differences, social workers should concentrate on critically listening to our clients’ autobiographies to reveal over time what aspects of their social and cultural lives matter to them” (Hollinsworth, 2013, p. 1048). Educating ourselves about specific groups that we are or might be working with is an important first step.

UNDERSTANDING CLIENTS’ INTERNALIZED IDENTITY AND SOCIAL REALITY

Before we can fully appreciate the lived experiences and worldviews of others, including our clients, we must first understand the dominant culture in the United States, where a Western, European/American-centered worldview dominates. Sue and associates (1998, p. 19) characterizes this worldview as follows: Rugged individualism, competition, mastery and control over nature, a unitary and static conception of time, a religion based on Christianity, separation of science and religion, and competition are a few of the values and beliefs indicative of this orientation.

Sue identifies other aspects of this worldview: 1. Competition (winning is everything; a win/lose dichotomy) 2. Action orientation (must master and control nature; a pragmatic/utilitarian view of life)

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3. Communication (written tradition; direct eye contact; limited physical contact; control of emotions) 4. Time (rigid adherence to time; time is viewed as a commodity) 5. Future orientation (plan for the future; delayed gratification) 6. Emphasis on the scientific method (objective, rational, linear thinking; causeand-effect relationships) 7. Status and power (measured by economic possessions, credential, titles and positions; owning goods, space, property, and other things)

Many of us share these beliefs and values and may have become so immersed in them that we do not realize that others hold a different worldview, which is as reasonable to them as ours is to us. When we assume that everyone subscribes to dominant traditions, beliefs, and values, we will be unable to enter our clients’ world. Race, Ethnicity, and Religion

With clients who self-identify as African American, black, and Afro-Caribbean, we must acquire an understanding of and appreciation for an Africentric worldview. This worldview emerges from three crucial African traditions, beliefs: collective identity, spirituality, and affective knowledge and expression (Tolliver, 2015). Collective identity means that each individual’s identity is rooted in the primary group and its collective survival efforts. The Africentric spirituality perspective, in contrast to the Western European/American-centered worldview, encourages a holistic view of individual and collective identity, soul, body, mind, and rationality and emotionality (Tolliver, 2015). Meanwhile, an Africentric worldview values affective knowledge and expression, where thinking and reasoning are influenced by and influence the experiencing of emotions. Similarly, thought processes affect emotions. Neither thoughts nor feelings act alone— they are interdependent. The Africentric perspective, in contrast to the western European/American-centered worldview, encourages a holistic view of individual and collective identity, soul, body, and mind, and rationality and emotionality (Tolliver, 2015). An Africentric worldview also reflects the history of slavery and the means through which the ancestors of most African Americans first came to the United States (Gilbert, Harvey, & Belgrave, 2009). Oppression, institutional and structural racism, and the destruction of African cultural norms and values have shaped this point of view in both positive and negative ways. “African Americans . . . survived historically because of values such as interdependence,

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collectivism, transformation, and spirituality” (Gilbert et al., 2009, p. 243). These values are reflected in the importance of kinship bonds that include nonrelated individuals and extended family members and community, flexible family roles that value strong maternal figures, and deep-rooted faith expressed through strong connections to black churches (Stennis, Purnell, Perkins, & Fischle, 2015). Mistrust of dominant social institutions and their representatives (which include social workers) is common, as is distrust of and resentment toward white people and those in positions of authority (Venable & Guada, 2014). Fatalism—akin to the notion of psychological impotence described in chapter 2—also may be an element of an Africentric worldview (Gilbert et al., 2009). Conceptualizations of male identity may emphasize aggression, sexual prowess, and material wealth in response to experiences of oppression and denigration (Griffith, Gunter, & Watkins, 2012; Venable & Guada, 2014). Parallels exist between an Africentric perspective and the worldview held by many of Latino and Hispanic heritage. There are numerous groups that are included under the umbrella term of “Latinx” or “Hispanic,” which makes it challenging to identify common cultural themes (Organista, 2009). “[Latinos differ] in colonization and immigration experiences, and politics; as well as ethnic-identity differences deriving from such factors as nationality, class, and skin color” (Cordero, 2008, p. 168). However, many Latinx and Hispanic individuals value family and community over individual identity. Maintaining group identification and cooperation is appreciated more than individual achievements and competition (Organista, 2009). Pride in one’s heritage and a desire to maintain cultural values and traditions are also common among individuals who identify with a Latinx or Hispanic heritage. This includes a preference for speaking one’s native language, Spanish and in some instances Portuguese (Lanesskog, Piedra, & Maldonado, 2015). Life circumstances are perceived as a matter of faith, chance, and luck, and often are out of a person’s control. The status quo is accepted and respected. Latinx/ Hispanic culture tends to have a hierarchical orientation. People in authority are granted expert status and are accorded respect. The hierarchical orientation also ties people to their elders and ancestors. Gender roles may be traditional, with men occupying the more powerful positions in family, community, and work life, and women responsible for child rearing and household management. The value placed on community and family is a source of strength and serves as a protective factor for the society (Cardoso & Thompson, 2010). This also can translate into a reluctance to seek outside sources of help. Personal problems, particularly if they involve mental health issues, may be a source of shame and viewed as a sign of weakness, particularly for men (Guerro, Campos,

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Urada, & Yang, 2012). Mistrust of outsiders—individuals not a part of the specific Latino or Hispanic cultural group—also may contribute to a reluctance to engage in help-seeking beyond familiar boundaries (Zadnik, Sabina, & Cuevas, 2016). Further, experiences with oppression and human rights violations may lead to a generalized fearfulness and a lack of safety and security. These feelings are likely to be exacerbated among those in the United States illegally (Zadnik, Sabina, & Cuevas, 2016). Asian culture also is an umbrella term that includes numerous diverse groups. While there are many differences, certain common values and belief systems exist. As with the Africentric and Latinx worldviews, the collective is valued over the individual. Death is more likely to be honored than birth, and there is a deep respect for elders. Traditional Asian beliefs reflect the religious teachings associated with Confucianism, Taoism, Buddhism, and Hinduism (Nguyen, Shibusawa, & Chen, 2012). While there are variations in each of these religious worldviews, a common theme is the interdependence of the mind and body and the need for balanced energy between the mind, body, and environment. Health problems indicate that this energy is weak or unbalanced. With respect to mental health, an Asian worldview assigns blame to the individual, who is assumed to have some sort of moral or character weakness (Chung, 2010). As a result, individuals with mental health problems often are stigmatized within their cultural group, leading to secrecy and unwillingness to seek help. A desire not to bring shame upon oneself and one’s family further contributes to a reluctance to seek help (Lee, Kim, Yamada, & Dinh, 2014). One of the more misunderstood cultural worldviews is that of Islam and Muslims. “Islam is not so much a belief system as a way of life . . . The word Islam means submission, specifically submission to Allah, the supreme and only God” (Hodge, 2005, p. 162). Muslims, those who practice Islam, believe that to honor Allah, they must adhere to God’s laws, which govern all aspects of life. One’s daily actions are always in service of the will and laws of Allah. Two divisions exist within the Muslim world, Shiite and Sunni. Sunni Muslims account for approximately 90 percent of Muslims worldwide, and they believe that the word of Allah is transmitted through a hierarchy of religious and legal scholars. Shiites believe that individuals can develop their own personal relationship with God. Islamic beliefs emphasize faith, humility, compassion, service to community, and honoring family. Open expression of one’s feelings or discussing personal challenges is frowned upon as a sign of preoccupation with self rather than respect for Allah. There are wide variations in traditions, values, and expectations due to the numerous cultural groups who practice Islam (Graham, Bradshaw, & Trew, 2009). In Muslim societies, gender roles tend to be clearly

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delineated. Women are afforded great respect, but the ways in which this respect is demonstrated may appear to many in the Western world to be a sign of repression and oppression (Chaney & Church, 2017; Kahn, 2015). The rise in militant and radical Islam reflects a distortion of the basic tenets of Islam, resulting from a complex array of geopolitical and economic factors. While adherents of traditional Islam focus on faith, family, and obedience to the will of Allah, radicalized Muslims are engaged in jihad, a so-called holy war to bring the rest of the world, particularly the Western world and the United States, under the rule of Allah (Wiktorowicz & Kaltenthaler, 2016). A final worldview that is too often neglected is that of Native (or Indigenous) Americans. We use this term in the most general of ways, as most American Indians prefer to be referred to by the tribe within which they were born. Each tribe has its own unique culture, traditions, and beliefs, but some overlap exists. Spirituality “permeates Native culture . . . Spirit, mind, body, and environment are all holistically and seamlessly interconnected” (Hodge & Limb, 2010, pp. 265–266). Physical and mental well-being depends upon oneness with the spiritual and physical worlds. The opposite also is true. Physical and mental health problems represent a disruption in an individual’s relationship with the spiritual world (Gone, 2007). Respect for elders, mutual respect between men and women, and close family ties with an extended network of kin also are aspects of Native culture (Limb & Hodge, 2011). A Native worldview also reflects the historical trauma associated with taking tribal land and the destruction of tribes and their traditions and colonization by white Americans in the form of boarding schools for Native children, concentrating Native tribes to limited geographical areas, and outlawing certain significant Native rituals (Braveheart, Elkins, Tafoya, Bird, & Salvador, 2012). This history has led to a Native worldview that often is characterized by fear, hopelessness, powerlessness, and lack of identity, particularly among Native men and boys (Braveheart et al., 2012; Gone, 2009). Gender and Sexual Identity

The women’s (or feminist) movement began in the late 1960s and initially focused on the pervasiveness of institutional sexism in education, work, healthcare, and family and community life (Orme, 2002; Saulnier, 2000). Some scholars express concern about the diminished importance in social work of feminist theory and its emphasis on sexism, power, and oppression (Rose & Hanssen, 2010). Others have argued that a feminist perspective is no longer relevant for social workers given the progress that has been made to eliminate institutionalized sexism

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(Valentich, 2011). Our view is that the principles and emphases of the women’s movement remain as relevant today as they were 40 years ago. The perspective has expanded to include institutionalized gender roles and expectations that have a profound impact on the actions and treatment of both men and women (Armstrong & Huber, 2015; Swigonski & Raheim, 2011). Sensitivity to gender requires us to acknowledge the continued existence of sexism and its manifestations: discrimination in the workplace, sexual and domestic violence against women, underrepresentation of women in positions of power in the public and private sectors, and limitations on women’s reproductive rights (Finn, Perry, & Karandikar, 2013; Levin, Woodford, Gutierrez, & Luke, 2015). It also demands that we recognize how gender expectations shape clients’ and our actions, values, beliefs, and views of each other. A gender-based perspective is more inclusive than a feminist one. It sensitizes us to the existence and consequences of sexism and gender-based expectations. Overt discrimination against women may have diminished over time, but gender-based expectations remain well entrenched in U.S. society, as do more subtle forms of sexism (Good & Rudman, 2010). To fully understand gender sensitivity, we start with definitions of the relevant terms. One’s sex is based upon physiology. Most individuals possess either male or female biological characteristics; other individuals are born with both male and female or ambiguous genitalia. Gender, or gender role, refers to how one enacts a male or female role based upon social norms and expectations. Gender identity is how one perceives oneself with respect to maleness and femaleness. This may or may not be consistent with one’s sex or assigned gender role (McPhail, 2008). Gender roles are narrowly defined, but gender identity is flexible and fluid. This perspective accommodates those who define themselves as transgendered. Initially, this term referred to “anyone who challenges the boundaries of gender and sexuality” (McPhail, 2008, p. 42). More recently, individuals whose identity and expression “differ from binary societal or cultural expectations associated with assigned sex at birth” (Austin, 2018, p. 73) may also define themselves as transgendered. Research indicates that the traditional binary notions of gender do not apply to significant numbers of individuals. The most recent U.S. Transgender Survey found that more than one-third of participants who identified as transgendered also saw themselves as nonbinary (James, Herman, Rankin, Keisling, Mottet, & Anafi, 2016). Therefore, individuals may more readily identify as gender diverse, gender neutral, and genderfluid rather than transgendered (Austin, 2018). Differences continue to exist between expectations for men and women, as well as for what men and women expect of themselves. This is despite the

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challenges to gender roles that the women’s and lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) rights movements created (Swirsky & Angelone, 2016). While wide variations in men’s and women’s gender identity do exist, differing expectations remain prevalent for gender roles: Women are nurturers and caretakers, men are doers; women are “emotional,” men are “stoic”; women are submissive and passive, men are assertive; women are followers, men are leaders; women are vulnerable, men are rescuers (Lansford et al., 2011). McPhail (2008, p. 44) notes that we are so immersed “in the gendered culture that [we] do not see the gendered assumptions and ramifications of [our] world.” Societal and internalized expectations lead to differences in help-seeking behavior and how men and women make meaning of and cope with life stressors (Needham & Hill, 2010). This results in differing rates of physical, behavioral, and mental health problems for men and women, and differences in how these challenges are manifested and responded to, as the findings of numerous studies reveal (Caputo & Simon, 2013; Khan et al., 2013; Kim, Shin, & Song, 2015; Lo, Monge, Howell, & Cheng, 2013; Mallett, Quinn, & Stoddard-Dare, 2012; Masterson, Hurley, Zaider, Corner, Schuler, & Kissane, 2015; Shafer & Wendt, 2015). For example: 1. When faced with life stressors, women tend to internalize stress, while men react by externalizing. Therefore, women experience higher rates of depression and anxiety and conditions like chronic pain, headaches, and arthritis. Men are more likely to engage in substance abuse and are at greater risk of high blood pressure, stroke, and heart disease. 2. Gender differences are apparent in both the nature and causes of juvenile delinquency. Adolescent girls are more likely to have underlying mental health problems like depression and be charged with “status offenses” (curfew violations, truancy, and “incorrigible” behavior). Adolescent boys are more likely to be charged with property offenses and crimes against persons and to be diagnosed with a conduct disorder. 3. Adult female offenders are more likely than men to have an underlying mental illness. 4. Men with substance abuse disorders are more likely to exhibit antisocial behavior, while women are more likely to be diagnosed with an underlying mood disorder. Women tend to have been abusing alcohol longer and in secret, making their road to recovery more challenging. 5. In response to the loss of a loved one, women experience more prolonged, internalized grief reactions than men. This includes depression, anxiety, and a variety of somatic complaints.

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Gender identity and sexual identity are often confused with one another. Gender identity is how one views oneself with respect to maleness and femaleness. Sexual identity, or sexual orientation, is the “self-perception of one’s sexual preference and emotional attraction” (McPhail, 2008, p. 35). Like gender identity, sexual identity need not fit neatly into a completely heterosexual or homosexual identity. Sensitivity to sexual identity requires us to understand the oppression and discrimination experienced by those whose identity is different from a heterosexual orientation. Homophobia, the fear of or intolerance for gay and LGBTQ individuals, and heterosexism, the assumption that the only “normal” sexual attraction is heterosexual, shape the social reality of individuals whose sexual identity lies outside of what is “heteronormative” (McPhail, 2008). Misconceptions about sexual identity further contribute to the challenges that LGBTQ individuals face. These misconceptions include that sexual identity is always and only about sexual attraction and contact; that LGBTQ individuals pose threats to children and will try to “convert” them and others to their lifestyle; and that LGBTQ individuals chose their sexual identity and could choose to be heterosexual. Traditional religious values and beliefs have been used to reinforce the assumption that individuals whose sexual identities are not heteronormative are “evil” and “sinners.” Overt discrimination against LGBTQ individuals has decreased, and certain basic rights have been granted like marriage, or reinforced, like protection from discrimination in the workplace. Yet one’s sexual identity often develops in secret, amid confusion and shame (Newcomb & Mustanski, 2010). Healthy identity formation depends upon a supportive social network that includes family, friends, and teachers. In most cases, LGBTQ individuals have grown up with heterosexual parents in an environment that is heterocentric. Individuals’ social network may convey messages that their developing sexual identity is wrong or abnormal. Compounding the problem is the fact that the social lives of children and adolescents revolve around traditions and activities that assume heterosexuality and a binary gender identity, including dating, play, and games. Children and adolescents whose behaviors and interests conform to LGBTQ stereotypes also are at high risk of being bullied, both in person and online (Russell, Ryan, Toomey, Diaz, & Sanchez, 2011). Given the condemnation and misunderstanding that continue to surround the LGBTQ community, it is not surprising that adolescents whose sexual identity is something other than heterosexual are at particularly high risk of suicide (Hong, Espelage, & Kral, 2011; Stone, Luo, Ouyang, Lippy, Hertz, & Crosby, 2014). The sexual identity of LGBTQ individuals may remain unknown unless they choose to come out. For some individuals, this life transition is an

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affirmative and empowering one (Corrigan, Kosyluk, & Rüsch, 2013). For many others, the process may be quite difficult (Legate, Ryan, & Weinstein, 2012). Research indicates that a supportive social network, particularly family, can mitigate negative consequences (Carnelley, Hepper, Hicks, & Turner, 2011). As acceptance of LGBTQ individuals has become more common, so has family acceptance (Carnelley et al., 2011). However, rejection remains a risk for many LGBTQ individuals (Baiocco et al., 2015). Research reveals that when family support is lacking, the impact on the LGBTQ individual can be minimized when other sources of support, acceptance, and validation are available (Baiocco et al., 2015; Snapp, Watson, Russell, Diaz, & Ryan, 2015). Another consequence of the stigma and misunderstanding that continues to surround different sexual identities is internalized homophobia and self-stigma (Corrigan et al., 2013; Warriner, Nagoshi, & Nagoshi, 2013). Individuals may accept their sexual identity but view it through the lens of the dominant worldview, which results in shame, guilt, and self-hatred (Greene & Britton, 2012). Given the stigma, misunderstanding, and confusion previously described, it is not surprising that LGBTQ individuals are at risk of mental health problems, often at a higher rate than those whose sexual identity is heterosexual. Age, Illness, and Disability

Preconceived and deeply held expectations exist in U.S. society based upon an individual’s age, much like those that are associated with gender roles. Ageism leads to “discrimination and social exclusion of a particular group of people based on their age, negatively impacting well-being and quality of life of the stigmatized persons” (Azulai, 2014, p. 2). These expectations create challenges at all phases of the life course, but they are particularly problematic for older individuals. While individuals are living longer than ever, characterizations of the elderly as childlike, incompetent, and irrelevant persist. This reflects the wider sociocultural context in the United States that values youth and vigor and fears and avoids dealing with death and dying. Negative attitudes reflect and reinforce institutionalized ageism, whereby aged individuals experience discrimination and restricted opportunities (Anderson, Richardson, Fields, & Harootyan, 2013; McNamara, Pitt-Catsouphes, Sarkisian, Besen, & Kidahashi, 2016). Ageist attitudes have contributed to some positive outcomes for elderly individuals in the form of senior discounts, accommodations on public transportation, and entitlements (Achenbaum, 2015). Yet these benefits reinforce stereotypes about the elderly that they are frail, needy,

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and dependent. As with some individuals who self-identify as LGBTQ, negative stereotypes about the elderly may be internalized and come to define how elders see themselves (Avidor, Ayalon, Palgi, & Bodner, 2017). Individuals with physical and, particularly, mental illness, as well as those with developmental and physical disabilities are widely stigmatized. Certain physical illnesses carry with them a stigma. These include AIDS, because of its association with homosexuality; cirrhosis of the liver, because it usually is caused by alcoholism; colorectal diseases, because they involve the bowels; obesity, because it is presumed to be the result of laziness; and many cancers, because of fear of contagion. Yet it is mental illness that carries with it the most negative associations, misconceptions, and misunderstandings. Throughout history, there has been a stigma associated with mental illness (Charles & Bentley, 2016). A lack of understanding of the various causes, coupled with the fear that some symptoms generate in others, explain why the treatment of those living with mental illness often has been harsh, punitive, and characterized by an “out of sight, out of mind” mentality (Charles & Bentley, 2016). Even as the last 40 years has resulted in significant advances in the understanding and treatment of many mental illnesses (like mood disorders, schizophrenia, and psychosis), stigma, social distancing, and misunderstanding remain the norm (Ahmedani, 2011). Many, if not most, mental illnesses have their origins in the brain’s neurochemistry. Yet it is still widely believed that mental illness is the result of immorality or weakness, and many individuals question the very existence of mental illness, assuming the individual is “faking it” or weak. Those living with mental illness and its effects often internalize the negative views of and messages surrounding it. This undermines their efforts to manage their illness and reinforces the stressors in everyday living that it poses. Shame and self-blame often prevent individuals from seeking help with the symptoms and problems they experience (Bril-Barniv, Moran, Naaman, Roe, & Karnieli-Miller, 2017; Crowe, Averett, & Glass, 2016). In addition, the stigma that is attached to mental illness often extends to the individual’s family members and support systems, who experience feelings of shame and blame, as well as embarrassment about their loved one’s illness (Liegghio, 2017). This undermines their ability to provide the support that individuals living with mental illness require. The stigma and negative assumptions that accompany mental illness result in oppression and discrimination, which can be evident in the treatment services that are designed to assist those struggling with its effects (Holley, Stromwall, & Tavassoli, 2015). This is manifested through talking about the individual

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as if he or she is not in the room, or overruling or dismissing the individual’s wishes or desires (Charles, 2013). Physical and intellectual disability also stigmatizes individuals. Research suggests that intellectual disability is particularly stigmatizing (Scior, 2016; Werner, 2015). Individuals who are intellectually disabled are routinely made fun of, bullied, and treated like children (Sherry & Neller, 2016). Further, their abilities and strengths often are underestimated or ignored altogether, and they are subjected to social distancing (Gormley, 2015; Renwick, 2016). Societal response to individuals with intellectual disabilities compounds and exacerbates their efforts to manage and cope. As with other groups, individuals with intellectual disabilities often internalize stigma (Monteleone & ForresterJones, 2017). Stigmatization also results in discrimination and oppression in the form of limited or nonexistent opportunities to make critical decisions, engage in independent behaviors, and participate in community life (Roth, Barak, & Perretz, 2016). Individuals with physical disabilities also face stigma, but the form that it takes is quite different. In most cases, it involves unwanted attention like staring, intrusive questions, and unwarranted solicitousness (Livneh, Chan, & Kaya, 2014; Silverman & Cohen, 2014). Widespread misunderstanding of and confusion surrounding many physical disabilities can lead to discrimination in the workplace and social isolation (Bulk et al., 2017). Individuals whose disability resulted from an accident, injury, or human-made or natural disaster face unique stressors associated with adjusting to their “new normal,” which includes a social reality in which they are treated and viewed differently (Dorstyn, Mathias, & Denson, 2011; Perrier, Smith, Strachan, & Latimer-Cheung, 2014). Microaggressions

As a nation, we appear to have become more tolerant of diversity. In some instances, this tolerance may be superficial and indicative of nothing more than political correctness. Whether genuine or not, greater tolerance has resulted in what is referred to as microaggressions (Kia, MacKinnon, & Legge, 2016; Seelman, Woodford, & Nicolazzo, 2017; Grant & Naish, 2016). Microaggressions are “brief, subtle, often unconscious, verbal slights or actions that convey hostile, derogatory, racist, sexist, homophobic, or other insults or messages of inferiority that become cumulative over time. [They] . . . may not be intentional, overt, or part of a pattern, [but] they still can have a negative effect on the person being targeted” (Robbins, 2016, p. 2).

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Sue and his colleagues (2008, p. 331) identify two manifestations of microaggressions, noting that in both cases, perpetrators are typically unaware of their actions and may even intend a compliment: 1. Microinsults: “Actions (verbal, nonverbal, or environmental) that convey insensitivity, are rude, or directly demean a person’s racial identity or heritage” 2. Microinvalidations: “Actions that exclude, negate, or nullify the psychological thoughts, feelings, or experiences of people of color”

We believe that microaggressions occur with any marginalized group, although as originally conceptualized, the idea was confined to race. Examples of microinsults and microinvalidations include: 1. Telling black/African American people that they are a “credit to their race” 2. Expressing surprise that a wheelchair-bound man can have children, or an aged individual is having or would like to have a sexual relationship 3. Speaking loudly and slowly to a Spanish-speaking individual who speaks accented English 4. Staring or doing a double-take at a same-sex couple holding hands 5. Questioning why a Muslim individual gets to take “time off ” from work to pray 6. Asking a U.S.-born Latina what country she was born in or telling her to go back to the country she was born 7. Wondering aloud what a rape victim might have done to provoke the perpetrator

Some of these examples are more directly insulting and invalidating, while others are subtle, and it is the latter microaggressions that present the greatest challenges to those who experience them (and to those of us who inadvertently commit them). The problem is that recipients may question whether they are interpreting the action or words correctly, or whether they are just overreacting (Robbins, 2016). Confronting the perpetrators of microaggression is often difficult because of their subtlety and because there actually may be no ill intent. “The power of microaggressions lies in their invisibility to their perpetrators, who are unaware that they have engaged in a behavior that threatens or demeans the recipient of such communication” (Sue, 2010, p. xv). The recipients of microaggressions also may have difficulty garnering support from others who assert they are just being overly sensitive.

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Multiple Intersecting Statuses (Intersectionality)

Earlier, we noted how approaches to cultural competence that focus on acquiring information about specific groups is limiting and unintentionally promotes stereotyping and leads to overgeneralization. We have argued that a “one size fits all” approach to cultural competence and sensitivity to diversity is insufficient to place us in our clients’ world. Social identity is multidimensional, and this is clearly reflected in the fact that many individuals occupy more than one social position. At the outset of this chapter, we introduced the term intersectionality, which addresses the fact that many individuals are part of multiple cultural groups and social statuses. Jani, Pierce, Ortiz, and Sowbel (2011, p. 295; emphasis added) note the multidimensional nature of this phenomenon: [Intersectionality] refers on one level to how the intersecting experiences of multiple subordinating identities contribute to one’s sense of self, perspectives, and aspirations. On another level, it refers to an individual’s multiple social locations that in some instances place him or her in the role of being both oppressed and oppressor simultaneously.

Acknowledging the existence of intersectionality helps us avoid overgeneralizing and assuming that all individuals within a particular social grouping experience their world in the same way. It also addresses issue of power, privilege, and social injustice. A powerful source of disenfranchisement is socioeconomic status. While it is beyond the scope of this book to present a comprehensive discussion of intersectionality, we provide a sampling of findings from recent research, which reveal its consequences: 1. African American women continue to be paid less than their white counterparts, black men, and white men at all levels of income (Nawyn & Gjokaj, 2014). 2. Compared to LGBTQ individuals from other racial, ethnic, and socioeconomic groups, poor African American gay men and transgendered men and women are at higher risk of being assaulted physically and sexually (Abelson, 2016). 3. While the risk of HIV is lower in Muslim communities relative to other cultural groups, Muslim men and women who are HIV positive are less likely to seek help than individuals from other cultural groups due to punitive attitudes toward homosexuality and ambivalence about female sexuality within their community (Hoel, Shaikh, & Kagee, 2011; Ikizler & Szymanski, 2014).

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4. Compared to women with a physical disability, disabled men are more likely to internalize stigma, and therefore experience depression and diminished feelings of self-efficacy (Brown, 2014). 5. Poor, economically disadvantaged African American female victims of domestic violence are less likely to seek assistance than their white counterparts due to stronger feelings of shame and self-blame and greater dependence on the perpetrator (Anyikwa, 2015). 6. LGBTQ individuals, as well as poor individuals of color, living with mental illness experience more stigmatization than heterosexuals and white individuals (Holley, Mendoza, Del-Colle, & Bernard, 2016). 7. Hispanic women are at greater risk than African American women and Hispanic and white men of exploitation in the labor force (Flippen, 2014). 8. For almost any risk factor or stressor, being a white male serves a protective function and promotes resilience (Mandel & Semyonov, 2016; Nawyn & Gjokaj, 2014).

Race, Power, and Privilege

Critical race theory addresses the complex relationship among race, power, and privilege. Critical race theorists focus on the ways in which racial groups are systematically marginalized and oppressed within the wider society and how this marginalization is perpetuated (Kolivoski, Weaver, & ConstanceHuggins, 2014). Race is more of a social construct than a biological one. Critical race theory emphasizes an individual’s social reality and internalized sense of self, both of which reflect social structures created and maintained by the dominant society. While it seems effortless for members of the dominant group to fit into existing societal structures, this is not the case for the nondominant groups (Ortiz & Jani, 2010). When we consider the effects of race, privilege, and power, our cultural competence and sensitivity to diversity are enhanced in two ways. First, we are required to enter the world of is because we are able to appreciate our client’s unique social reality. Second, we recognize how oppression and social reality shape clients’ views of themselves and us. Our goal is not to become color-, gender-, sexual orientation-, age-, disability-, or illness-blind. It is to understand the ways in which these and all other characteristics shape our clients’ lives, their views of themselves, their social world, and us, as well as the challenges they face.

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UNDERSTANDING OUR OWN CULTURAL IDENTITY AND SOCIAL REALITY

Self-awareness is critical to cultural competence and sensitivity to diversity. A first step in this process is to understand that as social workers, we are not immune from the biases, stereotypes, and inaccurate assumptions that exist within the society within which we and our clients live. There is a large body of research examining social workers’ and social work students’ perceptions of and reactions to diverse groups. A comprehensive summary of this research is beyond the scope of this book, but several examples underscore the critical importance of self-awareness: 1. Race and ethnicity. Clients of color often are assessed as having more serious problems, even when they are similar to those of white clients. Similar behaviors exhibited by whites and clients of color are viewed differently, with the latter’s behaviors being defined more negatively (i.e., hostile, aggressive, or resistant) (Gaston, Earl, Nisanci, & Glomb, 2016). 2. Gender. Social work is perceived to be a “women’s profession.” Women predominate in the field, and its values, ethics, and principles are consistent with expectations associated with women. Yet there have been numerous efforts to recruit more men into the profession as a way of enhancing its status (Pease, 2011). Further, men historically have occupied more senior positions in social work administration and education and have commanded higher salaries, even when relevant factors are controlled (Holosko, Barner, & Allen, 2016; Lane & Flowers, 2015). 3. Sexual identity. Because the profession places great emphasis on diversity, overt signs of homophobia are less apparent than the ways in which social workers’ professional judgments and practice decisions reflect heterocentrism (Denato, Craig, Lloyd, Kelly, Wright, & Austin, 2016). For example, intake questionnaires in most settings assume that a potential client’s spouse or partner is of the opposite sex, and clients are asked to state if they are male or female. 4. Age. The field of aging is one of the fastest-growing in social work, and yet social work students typically pursue other fields of practice, expressing negative attitudes toward the elderly and working with this population. This includes the assumption that working with the elderly is “depressing” (Chonody & Wang, 2014). In several studies, professional social workers have expressed beliefs and attitudes that can be viewed as ageist (Allen, Cherry, & Palmore, 2009). 5. Mental illness. Social workers’ attitudes reflect negative attitudes toward and stigmatize the treatment of clients with mental illness, including underestimating or

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discounting strengths (Araten-Bergman & Werner, 2017; Charles, 2013). Social work students have expressed reluctance to work with mentally ill clients, fearing for their safety. In reality, individuals living with mental illness are more likely to be victimized than to victimize others (Zellmann, Madden, & Aguiniga, 2014).

Self-reflection requires that we operate from the “should versus is” principle. We should avoid a priori assumptions about our clients based upon societal expectations. However, we are human, and products of the world in which we live. If we are going to be open to our clients’ social reality, we must start with the world of “is,” which reflects our beliefs and assumptions, our lived experiences, and our social reality. Privilege and Humility

An essential aspect of being in the world of “is” is to understand what researchers have referred to as white privilege. Many of us have benefited from this, whether we realize it or not. Others of us have experienced its negative effects, again whether we realize it or not. White privilege is the result of racial stratification whereby white people are privileged, and people of color are disadvantaged, based simply upon skin color (Abrams & Gibson, 2007). Those who have it typically have not earned it; their advantaged position resulted simply from their race and/or skin color (Nicotera & Kang, 2009). We propose that privilege extends beyond race and includes any instance when those in a majority, valued position enjoy benefits and privileges relative to—and often at the expense of—others who occupy a less valued social niche. Therefore, it is critical that we consider the ways in which other social positions and identities privilege us (Conley, Deck, Miller, & Borders, 2017). Operating from this more expansive view of privilege, we can see the ways in which the social positions that we occupy based upon race and ethnicity, gender, age, socioeconomic status, ability, and health benefit us (or not). Our intent is not to generate guilt or assign blame. We are not “antiwhite,” “antimen,” “antiheterosexual,” or anti-any group of individuals that benefits in some way from being in a more socially powerful position relative to another group. Rather, we want social work students to fully understand and appreciate the world of “is.” Both of the authors of this book are white. Neither one of us encourages or supports white privilege, but we recognize how it has benefited us in our work, personal, and social lives. Both of us are heterosexual; yet we are keenly aware of how our sexual identity has advantaged us in a society that continues to be at best heterocentric, and at worst homophobic. Both of us are abled and clearly

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see how the deck is stacked against those who are not. Both of us, however, are aging, and therefore we have experienced firsthand how this status can define and restrict us and create barriers to full social engagement. Social work students also must consider how their lack of social privilege shapes their worldview and social reality. This includes acknowledging feelings of guilt resulting from a reluctance to “rock the boat” due to fear of repercussions or the belief that nothing will change, reflecting the psychological impotence discussed in chapter 2. Students also may struggle with self-blame for not standing up to the social injustice they have experienced firsthand, as well as resentment at their inherent vulnerability (Smalling, 2015). We must understand that our professional position itself affords us a privileged status relative to our clients (Nicotera & Kang, 2009). As the distance between our clients and us widens due to differences in race, gender, culture, income, and other factors, our privileged position becomes even more apparent and potentially problematic. Unlike most socially privileged positions, being a social worker is an earned privilege (Weinberg, 2015). With the rights associated with this position comes the responsibility to lessen the distance between our clients and us and empower them to move beyond the limitations imposed upon them by the social positions they occupy. We also have the responsibility to oppose the marginalization of others and advocate for equal access and opportunity for all. Weinberg (2015) reminds us of the ways in which our privileged position may disenfranchise our clients. As social workers, we have the power to: 1. 2. 3. 4. 5.

Define what constitutes the nature of the help we provide Be viewed as credible Establish the terms of the relationship that we have with our clients Decide how much our personal selves we reveal to our clients Define standards for health and illness, normalcy and pathology, and good and bad

The more we view our relationships with our clients as a partnership, the more these sources of power can be transformed to advantage them, not us, and promote their interests, not ours. As we noted, most of us have not earned our social privilege. It is so embedded in our daily lives that we take it for granted (Kondrat, 2002; Todd, 2010). We understand that social work students will struggle with the concept of social privilege. We agree with Nicotera and Kang (2009, p. 190), who observe that because many students are “[immersed] in privileged social groups, [and this]

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leaves them blind to ways in which unconscious patterns of behavior, on their part, maintain the very issues they may be inspired to eliminate.” Walls and colleagues (2009) found that social work students are able to understand how their cultural identity shapes their social reality, but they struggle with examining social privilege in their own lives. They suggest that many students must go through the following stages to achieve understanding and acceptance. These stages include: 1. 2. 3. 4. 5. 6. 7.

Denial Fear that social privilege may be a reality Questioning how widespread social privilege really is Acknowledging the pervasive existence of social privilege Acknowledging complicity Guilt Acceptance and commitment to resisting social privilege

We end this discussion with a first-person account of one social worker’s journey toward understanding social privilege (Spencer, 2008).1 The author, who is Native Hawaiian and self-identifies as mixed race, has experienced both the benefits and the disadvantages of his social privilege. We cannot improve upon his words, so we present them unedited, italicizing observations that we think are particularly powerful: As a person of color, I am often placed in a position in which I must process the disrespect I perceive or the assumptions that others make of me . . . I know what it is like to be grabbed by the arm at a campus restaurant . . . and be asked to bring people their drinks. I also know what it is like to seek the support of a friend following this incident and be told, “That could have happened to anyone” (p. 99).

Spencer contrasts his experiences growing up in a marginalized group with those associated with his privileged status as a professional social worker, acknowledging his ambivalence: My education has moved me from my status as a child growing up in an impoverished neighborhood . . . to a middle-class professional . . . I have the privilege of selecting the “right” neighborhood with the “right” schools so that my children will have the best chance in life. I remember the shame I felt about where I lived as a child and the shame of using food stamps . . . Today, I know what it is like to spend the equivalent of another family’s weekly, or even monthly, grocery budget on one meal (p. 100).

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And, finally, Spencer reflects on other positions of social privilege that he now realizes he occupies, including on being a man: I benefit from the objectification and subordination of women. I do not have to worry about whether I . . . [can] walk through the alley that is a short cut to . . . where my car is parked. One evening after work, as I was walking to this garage with a female colleague, I found it entirely inconvenient that she did not want to walk down the alley. . . . It did not occur to me that women have been sexually assaulted in this alley. As a man of color, I often feel like I do not possess the same privileges of maleness as white men. However, that evening in the alley, I realized the privilege of assuming physical safety (p. 100).

On being a heterosexual man: I also benefit from identifying along the male–female gender binary. I present very much as a man. No one ever has to wonder what pronoun to use with me. I also do not have to worry that if my fingernails or hair get too long that someone will realize I am not the gender I present . . . The thought that someone would want to beat me, rape me, or kill me because of my gender identity and expression has never crossed my mind. I do think about my sexual orientation or at least how I present myself as a heterosexual individual. Growing up, the worst thing in the world someone could call me was “gay.” . . . Today, I am aware of the violence that the gay, lesbian, and bisexual (GLB) population face on a daily basis. I deplore this and actively work as an ally. However, I still think twice before I pull out my pink shirt (p. 99).

On being able-bodied: As an able-bodied person, I do not have to take into consideration the time it will take me to find an accessible entrance and figure out how I will be able to get to where I need to go . . . I have never had to ask for accommodations, for extra time to finish an exam, for large print, or for real-time captioning. I know the privilege of people assuming that I have full cognitive capacity based only on my physical appearance. As a person of color, though, I can relate to being gawked at and stared at by people who are not used to seeing “my kind” (p. 99).

And, finally, on being complicit in maintaining social privilege: This past fall, I recall standing on the sidelines at my son’s football game and hearing fathers refer to boys as “pussies” when they were not as aggressive as they should be. I should have said something, but I did not . . . I wanted to keep every drop of privilege

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that comes with being a heterosexual man. I chuckled a little, but with this chuckle, I perpetuated the discrimination of the GLB population and condoned the violence they experience. I did not need to say anything—just chuckle—because oppression does not require me to actively discriminate to perpetuate it; it just requires that I do nothing to stop it (p. 100).

A complementary concept to privilege is that of humility (Smalling, 2015; Rosen, McCall, & Goodkind, 2017). Humility requires us to recognize that we may occupy a privileged position simply by being who and what we are and/ or by an accident of birth, not as a result of anything we have done (FisherBorne, Montana Cain, & Martin, 2015). Ortega and Coulborn (2011) suggest that cultural humility results in an acceptance that the social world that we and our clients inhabit is far more complex and dynamic than we have previously understood or imagined. We cite once again Spencer’s insightful article: “[Humility] means never being truly culturally competent, but rather, recognizing that the pursuit of critical consciousness is a lifelong process. My reflection as a social worker continues, for I am still a work in progress, and I would like to encourage my fellow social workers to also continue with such reflection (Spencer, 2008, p. 99). What we want for students—especially the readers of this book—is that they will engage in the same process of self-reflection and honest assessment that Spencer so courageously shares with us. Blame, guilt, accusation, and resignation may be part of the self-reflection journey, but they are not the end state. We hope that the outcome of this ongoing process will be an acceptance of what is and a commitment to pursuing what should be. Cultural humility requires social workers to replace generalizations and stereotypes about a client’s culture with genuine curiousity. The clients can become our teachers about the personal meanings of their cultural experiences (Grauf-Grounds & Rivera, 2020).

EMBRACING DIVERSITY IN OUR PERSONAL LIVES

Research consistently demonstrates that we tend to live among and socialize with people just like us. One way to expand our understanding of our clients is to expand our social networks to include people who are different from us. The social reality of others is no longer academic and distant, based upon what we may have learned from books, classes, and our clients. We witness and experience others’ social reality firsthand. In advocating for the expansion of students’ social networks, we are not suggesting that, for example, a white student specifically

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seek out black/African American, Hispanic/Latinx, or Muslim individuals to be friends with so that they can be better social workers. We are not suggesting that abled students or heterosexual students seek out disabled or LGBTQ individuals to serve as our teachers. However, we are suggesting that as we move beyond the familiar and enter the world of “others,” our understanding of the impact of social privilege, intersectionality, and prejudice and discrimination is enhanced, which in turn enhances our cultural competence and sensitivity to diversity. We can expand the diversity of our social networks in many ways: engaging in recreational and social activities that appeal to diverse individuals; attending events that attract, support, or promote social justice and equal rights for marginalized groups; and reaching out to classmates, fellow employees, and neighbors to have conversations about shared interests. When we engage with individuals in our social lives whose social reality differs from ours, we are not social workers—we are just human beings interacting with other human beings (Sue et al., 2015). The personal lens through which we view diverse worldviews and social realities complements the professional lens that results from our academic knowledge and professional experiences with clients. When we engage with diverse groups of individuals and are involved with diverse social networks, we are especially likely to observe examples of microaggressions. Both of us have witnessed microaggressions and manifestations and consequences of social privilege, discrimination, and marginalization in our personal social networks, including the following: One coauthor of this book and her spouse were out to dinner with their friends, a gay couple, who were celebrating their anniversary. Each couple was holding hands when the server came to the table. All of us noticed the disapproving, startled look that he gave them. The author’s friends quickly stopped holding hands and were embarrassed. A close friend, an African American man, and one coauthor were talking about the challenges of raising their teenage sons, who are the same age, and their choices in clothing. She bemoaned the fact that her son was going through his “baggy pants and backward baseball cap” phase. Her friend noted that his son was “forbidden” to wear such clothing because he worried that his son would be mistaken for a “gangster.” A close friend of one coauthor is an African American woman, twenty years her senior. On numerous occasions, particularly as her friend has aged, when they meet for lunch, servers direct their comments to the coauthor, not her friend.

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Table 4.1 summarizes considerations associated with developing sensitivity to diversity and cultural competence. Table 4.1 Considerations Associated with Sensitivity to Diversity and Cultural Competence Continually seek to understand clients’ cultural and social identities and social realities

• Microaggressions • Stigmatized and internalized identities • Microaggressions, microinsults, and microinvalidations • Multiple intersecting identities

Continually seek to understand workers’ cultural and social identities and social realities

• Social privilege • Cultural humility

Seek opportunities to engage with others from diverse backgrounds

• Experience firsthand the social reality of others

Cultural Competence and Sensitivity to Diversity: Case Examples

We end this chapter with several examples drawn from our students’ practice to underscore the complex nature of cultural competence and sensitivity to diversity, as well as their critical importance in social work practice. In subsequent chapters, we will delve into these issues in greater detail, identifying social work skills that help us engage and work with our clients in ways that respect their social reality. Case one. Shevonne, a 32-year-old, woman who identifies herself as a black American, was placed at an outreach program for teen parents. The program helps young mothers and fathers learn parenting skills, provides support to them as they assume this role, and also seeks to reduce the likelihood of subsequent pregnancies. Shevonne is the single mother of five children and had her first child at age 15. She is the only black social worker at the agency; the clients are predominantly black/African American adolescents. Shevonne’s field instructor, Sally, informs her during the first week of her field assignment that she will be working with the black/African American girls in the program because other staff have found them “challenging” and “difficult to engage” in a working relationship. Sally also indicates that Shevonne’s own experience of being a single parent will aid her in her work.

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Initially, Shevonne assumes that it will be easier for her to connect with her clients because of their shared racial identity and personal experiences of teen parenting. After three weeks, Shevonne expressed frustration and bewilderment that her clients were as “disrespectful” to her as they were to other staff. She described in class her efforts to connect with her clients by sharing with them her experience as a teenage mother and wondered why they were so “resistant” to her efforts to engage them. She was especially bewildered by the comments of one client, who said, “You ain’t no different than any those other white ladies!”

We suggest that Shevonne was set up by her field instructor and her own naivete to have problems engaging with her clients. She assumed that sharing the same race as her clients, as well as a similar life story, would enhance her ability to engage with and understand them. What Shevonne—and her field instructor—failed to appreciate is that those surface similarities masked significant dissimilarities. These included age (Shevonne was more than twice the age of most of her clients); social status (Shevonne was a well-educated social work student, while most of her clients were from impoverished backgrounds, attended poorly funded schools, and were at risk of dropping out); and social network (Shevonne grew up in a stable, two-parent family and enjoyed continued support from her family and the fathers of her children, whereas most of her clients grew up in single-parent families in which there often was addiction, violence, and neglect). Shevonne and her field instructor also failed to anticipate that her clients might initially assume that she was like them. Her client’s comment about her “being like the other white ladies” was prompted by Shevonne’s questioning her about her unwillingness to use birth control. The client assumed— incorrectly—that Shevonne would understand and support her lack of interest in birth control. Shevonne, her field instructor, and her clients all operated under the mistaken belief that similar skin color equated to similar worldview and social reality. Shevonne quickly learned that her and her clients’ assumptions could become barriers to establishing a partnership unless they were directly addressed. She understood that she needed to use skills such as explaining her professional role and searching for and acknowledging the existence of doubts and ambivalence (discussed in chapter 7) if she wanted to enter her clients’ world. This meant she had to see herself as they saw her. We must understand that our helpfulness does not depend upon similarities—either

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real or perceived—between our clients and ourselves. It stems from our ability to put ourselves into their world. Case two. Monica is a 20-year-old white social work student placed at a food delivery program for the elderly. Her delivery of meals also serves as a well-being check and an opportunity for her clients to socialize, since most are socially isolated. Most of Monica’s clients are low-income and of black/African American or Hispanic heritage. Monica is scheduled to meet her first client in the upcoming week, and she shares her belief with fellow students that she has nothing in common with her clients and worries that they won’t take her seriously. The coauthor encouraged her and her classmates to think about the world in which her clients live. This includes considering what it is like to live on a limited income; have few living friends and few visitors; have experienced discrimination and oppression; deal with failing health; and have some young “whipper-snapper” offer to help.

As the class engaged in this process of anticipatory empathy (discussed further in chapter 6), Monica began to see how she could bridge the divide between her clients and her. Monica’s concerns actually helped her tune in to her clients. It is likely that they would have reservations about her, and would question how she could be helpful. In recounting to the class how her first home visits went, Monica described how she put into words her clients’ reservations about her, as well as possible challenges they faced, such as loneliness and loss. Monica also used self-deprecating humor, saying to several clients, “I’ll bet I am younger than your grandchildren, so no wonder you might be asking, ‘What can this little girl do for me?’ ” Monica’s misgivings allowed her to anticipate in advance how her clients might perceive her. This allowed her to develop an introduction about herself and her role that took clients’ reservations into account. Monica was able to use humor about herself in a way that reduced the differences between herself and her clients. Initially, she acknowledged that she was somewhat threatened and offended when clients agreed that she reminded them of a grandchild (in one case, a great-grandchild!). She quickly learned, however, that this was not a criticism, and her discomfort was more about her questions about her ability to be helpful than her clients’ doubts about her. Case three. Rinaldo is a 24-year-old social work student who was born in Guatemala and emigrated to the United States with his family when he was 8 years old. Spanish is his first language, and he speaks accented English. He is placed in a prerelease

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center for incarcerated men who have served their time and are being discharged from prison. Rinaldo’s role is to assist his clients’ transition back into their communities. He helps them secure housing, employment, and appropriate resources. His newest client is Gilbert, a 30-year-old white man who was in prison for drug possession. In his initial interview with Gilbert, Rinaldo asked him what his living arrangements were going to be upon his discharge. Gilbert informed him that he was going to be living with his “boyfriend.” Rinaldo expressed pleasure that Gilbert had such a “good friend” to lean on. In class, Rinaldo expressed his confusion, offense, and embarrassment at Gilbert’s response to his comment: “Don’t you understand English, bro? Brian [the friend] is my boyfriend, not my friend. You don’t have homos in Mexico?”

Rinaldo characterized the rest of the interview as awkward and unproductive. He expressed regret that he was so “stupid” as to not realize that Gilbert was gay. With some reluctance, he revealed that he wasn’t “comfortable” around gay people because it was against his Catholic religion. Several classmates rolled their eyes in response to his comments, with one individual saying, “It’s not ethical to not like gays!” Unlike some of his classmates, we are not disappointed in or upset with Rinaldo. He, like all social workers, is entitled to his belief system. It was not what we believe that is problematic, but rather what we do in response. Like many novice (and even experienced) social workers, Rinaldo adopted a heterocentric perspective. Rather than condemning him for his error, we credit him for being honest in describing what happened and for acknowledging his beliefs and how they affected his interactions with Gilbert. We will never be able to develop cultural competence and sensitivity to diversity if we are unable or unwilling to first recognize our values, assumptions about others, and principles. It was important for Rinaldo to question whether he could set aside his discomfort so he could enter Gilbert’s world. To his credit, Rinaldo worried that he could not do this. We believe that if Rinaldo can see Gilbert as a person, not just a gay person, facing the understandable challenges associated with reentry into the community following incarceration, he will be able to connect with him. We also believe that Gilbert’s sarcastic reply might reflect his feelings of being discounted and devalued, not just by Rinaldo, but by the wider society, as well as assumptions that he was making about Rinaldo’s heritage. In subsequent chapters, we will revisit in depth the challenges reflected in this example, particularly the worker’s personal values and taking offense at a client’s behavior or comments and making a mistake. Briefly, the challenge

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for Rinaldo moving forward was to revisit this exchange with Gilbert in their next session. Rinaldo worried that he had “lost” Gilbert and had “failed” in his attempt to engage him. We disagree. Rinaldo is only human. He—indeed, all of us—make mistakes. What we do when this happens is what counts. Rinaldo developed a plan for his next meeting, which began with apologizing for his mistake and putting into words how he thought Gilbert might be feeling about it. When we make a mistake, we have the opportunity to deepen our work with our clients. We convey to them that we do not have to be—and are not—perfect, and neither are they. Rinaldo reported that Gilbert accepted his apology. He also reported that the more he and Gilbert talked, and the more he discovered about Gilbert, the more he let go of his discomfort and entered his world and the challenges that it presented, associated with his race, criminal history, and sexual identity. We end this chapter with a final anecdote drawn from one coauthor’s work with adult survivors of childhood trauma: I was preparing to start a support group for survivors and was interviewing prospective members to collect a brief social history, explain the group and its purpose as well as my role, and assess the individual’s appropriateness for the group. When Doris walked into the office to meet me, I extended my hand, and she exclaimed, “Ain’t you some white lady!”

When I share this example with students, their reaction is inevitably, “Oh, no! I sure hope that never happens to me!” And my response is always the same: Doris gave me a gift. She handed me her concerns about me on a platter; I did not have to search for them. She had the courage to tell me right up front that she was not sure I could help or understand her. Her questions about me were justified. Doris is white, like me. However, this is where our similarities end. She dropped out of school in the eighth grade and grew up in desperate poverty in the mountains of West Virginia. She was sexually abused by numerous men in her family and physically abused by her mother. She could barely read. So we shared the same skin color, but in every other way, we were very different. In just one statement, Doris shared with me her belief that I could never possibly understand the world in which she lives. Informing her of my long experience working with survivors or my genuine desire to help her would not address her concerns. What would is to acknowledge her reservations, convey to her that they are legitimate, and then invite her to share them with me, as well as assist me in entering her world. My response was quick and spontaneous.

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I smiled and said, “Whoa, you sure put me in my place, didn’t you?! How about you tell me what you’re thinking about being here with me?” We should all hope that our clients are as courageous as Doris. Most will not be as forthcoming, however. Therefore, it will be up to us to be courageous and to raise their concerns about us directly, early, and nondefensively. This is the essence of culturally competent and diversity-sensitive practice.

Assessment, Evidence-Guided

FIVE

Practice, and Practice Evaluation

ASSESSMENT

Assessment is an essential element of all practice approaches. Social workers make informed choices as the helping process begins and throughout their work, including where and how to enter their clients’ lives and social worlds, make meaning of clients’ verbal and nonverbal and direct and indirect communication, develop a plan for work, and select appropriate intervention strategies. Assessment is a product. In our earliest encounters with clients, it is critical that we develop mutually agreed-upon directions and foci for our work together. Assessment also is a process that is ongoing. The initial plan of work may be revised as new information becomes available or as clients and workers develop a greater understanding of how their work together can be helpful. Further, in each client encounter, we are constantly evaluating what is happening. This includes asking ourselves (and clients, when needed) questions such as: What is the client really saying to me here? Are we on the right track? Are we making progress? Do we need to make some adjustments in our plan of work? Do the client and I understand what each other is saying? Are we on the same page?

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Assessment requires reasoned thought when making judgments at any moment during a session, as well as when constructing a formal assessment of person:environment exchanges. To be valid and useful, our professional decisions and the assessment itself must be rooted in logical reasoning and inferences based on available evidence. Both the process of assessment and the product require a general understanding of human behavior and the social environment, methods of intervention, and relevant empirical evidence. Both also depend upon knowledge of specific clients based upon our observations and the information we collect. In this chapter, we focus primarily upon core aspects of assessment with individuals, families, groups, and communities. We also briefly introduce elements of assessment that are unique to families, groups, communities, and organizational change. In chapters 10, 11, 14, and 15, we discuss in more detail the assessment considerations for each of these modalities. Assessment Tasks

To develop reliable judgments, social workers must construct assessments in partnership with their clients. Their shared tasks include the following: 1. Collecting salient information on the nature and severity of clients’ life stressors, clients’ perception of and responses to the stressors, clients’ expectations of the worker and the agency, clients’ strengths and limitations, and pertinent environmental resources and gaps. 2. Organizing this information in ways that reveal significant patterns. Clients often face numerous life stressors that may overwhelm both them and the worker. Therefore, the worker needs to organize the information in a way that clarifies clients’ current adaptive balance or imbalance and reveals the level of environmental fit. This provides direction to workers and their clients’ collaborative efforts. 3. Analyzing and synthesizing the information to draw inferences about client strengths and limitations, environmental resources and deficits, and level of fit between person and environment. This analysis includes an assessment of the impact of clients’ position within their social environment based upon race, ethnicity, gender, sexual orientation and identity, socioeconomic status, age, health, and ability, as discussed in chapter 4.

In most instances, clients are the primary source of information upon which assessments are based. Social workers begin to develop an understanding of what is going on in clients’ lives by actively listening to what clients tell us, verbally and nonverbally and directly and indirectly. Sources of data include the

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client’s verbal accounts, the worker’s observations of the client’s nonverbal communication, and, at times, information provided by others, which may require the worker to get the client’s permission before obtaining it. This could include teachers, parents, and previous or current providers of health and mental health services, as well as written reports. When we collect information from significant others in clients’ lives, we must remember that they are providing us with their interpretation based upon their unique interactions with the clients. Since large of amounts of information can be confusing and overwhelming, workers must develop a system of making sense of what they have learned. Two types of reasoning assist in this task. Deductive reasoning applies general practice knowledge and research findings to specific client situations. Inductive reasoning relies upon the information that the worker has collected about specific clients to make informed judgments—or inferences—about what the information means. Case Example: Inductive and Deductive Reasoning. LeAnne has sought help from Barb, a social worker, because she has been depressed and cannot seem to “snap out of it.” In their first session together, Barb begins to collect information from LeAnne that will assist the two of them in identifying what is going on and how their work together can be helpful. As she begins to develop her assessment, Barb asks questions that reflect her a priori understanding of depression, its causes, and symptoms based upon theory and research. This requires her to use deductive reasoning. Her questions are not yet driven by LeAnne’s unique situation. Barb’s knowledge of the research on mood disorders is particularly critical to her developing an accurate assessment.

Research findings have significantly enhanced our understanding of mood disorders like depression. Without the benefit of this evidence base, Barb is likely to conclude that LeAnne’s depression is solely or primarily the result of some sort of stressful life transition, like problems at work or disruptions in social relationships. Barb must consider, for example, the neurobiochemical basis of depression and ask questions about symptoms such as difficulty in sleeping, loss of appetite and interest in daily activities, and agitation. Research suggests that depression often is both organic (i.e., the result of malfunctioning of neurotransmitters in the brain) and situational (i.e., the result of something occurring in the individual’s environment) (Holley, Stromwall, & Tavassoli, 2015). Situational and organic factors become self-reinforcing. Therefore, Barb also must explore what environmental elements might be contributing to LeAnne’s depression, like problems in her relationships or employment, or any precipitating events, like the death of a loved one.

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Barb uses inductive reasoning as she interprets LeAnne’s responses to her questions. This requires her to attend not only to what LeAnne tells her, but how she tells her story. Let us contrast several scenarios that might transpire when Barb asks LeAnne about her work life: Scenario 1: LeAnne replies in a neutral, matter-of-fact tone, “Well, I like my job just fine. It pays the bills, doesn’t require me to think a lot, and is low stress. What’s not to like?” As she says this, she maintains eye contact with Barb and smiles. Scenario 2: LeAnne replies in a soft tone, “Well, I like my job just fine. It pays the bills, doesn’t require me to think a lot, and is low stress. What’s not to like?” As she says this, she looks down, fidgets in her seat, and twists her hair. Scenario 3: LeAnne loudly replies, “Well (hesitates), I like my job just fine. It pays the bills, doesn’t require me to think a lot, and is low stress. She hesitates and then adds, loudly, staring intently at the worker and with her fists clenched, “What’s not to like?!”

In each case, the client’s verbal response is the same. However, Barb is likely to draw different inferences about LeAnne’s satisfaction with her work—and whether this might contribute to her depression—based upon the client’s nonverbal and indirect communications. In the first scenario, LeAnne verbally tells Barb that her work life is fine. Her nonverbal communication, in the form of eye contact, tone of voice, and facial expression, supports her verbal response. Barb’s inference that LeAnne’s work life is going well is supported by the congruency between her verbal and nonverbal communication. In the second and third scenarios, assessment using inductive reasoning becomes more challenging. LeAnne’s verbal response indicates that her work life is fine, but her indirect communication—conveyed nonverbally—suggests that there may be more to the story. In the second scenario, LeAnne’s nonverbal communication suggests that she may be embarrassed or in some way upset about her work situation. In the third scenario, her nonverbal communication— conveyed primarily through her tone of voice and facial expressions—suggests some resentment or defensiveness. In either of these cases, Barb’s inferences about LeAnne’s job satisfaction will be incomplete until she addresses the incongruence between LeAnne’s verbal and nonverbal communication. In the second scenario, let us say that Barb concludes that LeAnne does not like her work, but she does not check this inference out with her. What Barb does not know—because she did not ask—is that LeAnne has cerebral palsy,

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which is the cause of her “nervous” behaviors. In the third scenario, Barb infers from LeAnne’s nonverbal behavior that she is angry and “defensive” and therefore must not like her work. This inference also could be inaccurate. LeAnne, in fact, loves her work. However, her boyfriend, who is unemployed, complains that she does not bring in enough money and keeps insisting that she find something else that pays more. The problem, then, may not be LeAnne’s work per se. It is the pressure that her boyfriend is placing on her about it. Barb’s assessment of the sources of LeAnne’s depression—and therefore the nature of their future work together—ultimately will be based upon what her client tells her verbally and nonverbally, as well as what she already knows about mood disorders. What the last two scenarios reveal is the importance of workers having sufficient information to support any inferences they make. Cultural competence and sensitivity to diversity will help us arrive at accurate inferences and interpretations. This includes considerations associated with working with clients for whom English is a second language. The client’s response to the social worker and to the interview might be incorrectly assessed. When people are uncertain about their ability to communicate in their second language, they might act in a guarded, diffident manner. The social worker cannot infer from this behavior that the client is uncooperative, withholding, or lacking in self-esteem. A client’s motor activity may reflect a language problem rather than an underlying mental health symptom. Problems in cognitive sequencing and logic should not be confused with difficulties caused by communicating in a second language. The social worker also must be careful about misinterpreting the meaning of the client’s affective and emotional communication. Finally, the social worker should be cautious when making inferences about self-identity and self-esteem. Clients may convey a completely different sense of self in their native language than in their secondary language. What the worker understands to be a lack of self-confidence may be nothing more than clients’ concerns about being understood or understanding others when using their second language. Cultural values and traditions may confound our efforts to understand clients’ nonverbal behavior. Marianne is placed in a senior center and is working with an 87-year-old Chinese-American woman, Sally, who never looks at her when they meet. With the help of her supervisor, Marianne realizes that in Sally’s culture, deferential behavior, like looking down rather than at a speaker, is a sign of respect, particularly when meeting someone new or unfamiliar. Workers also must consider their own cultural traditions associated with communication. Daraja, a 20-year-old social work student from Nigeria, noted that many of her clients, residents of an assisted living facility, seemed uncomfortable with her. She expressed concern to her field instructor that she was

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having trouble engaging with them. Her field instructor observed that in their supervisory sessions, Daraja tends to look at the floor rather than at him. He suggested that she might be doing the same thing with her clients, which might explain their behavior. Daraja confirmed that in her culture, it is considered rude for a young person to look directly at an elder when speaking. Life-Modeled Assessment

The three assessment tasks—collecting, organizing, and analyzing and synthesizing information—are common to all practice approaches. However, three underlying principles are distinct to life-modeled practice. First, life-modeled practice emphasizes client participation in the assessment process. Involvement ensures shared focus and direction and supports culturally and diversity-sensitive, empowering, and ethical practice. Second, as noted, large amounts of information can overwhelm both worker and client. The life stressors formulation of stressful transitions and traumatic events, environmental pressures, and maladaptive family or group relationships and communication patterns provides a framework to organize information. This in turn suggests the nature of our interventions. Third, life-modeled practice emphasizes assessment of the perceived level of fit between human needs and personal and environmental resources. To understand the importance of life-modeled assessment, let us briefly return to LeAnne. After collecting information on various aspects of LeAnne’s life and social functioning, Barb speculates that LeAnne’s depression may be the result of a possible biochemical imbalance (organic) and her relationship with her boyfriend (situational), consistent with our elaboration of scenario 3. From a life-modeled perspective, LeAnne’s boyfriend’s lack of employment, coupled with his demands that she earn more money, has created stress for her. Her vulnerability to depression that results from a biochemical imbalance undermines her ability to manage and resolve the stress associated with her boyfriend’s demands. This stress also exacerbates the problems with her mood. Put another way, the level of fit between LeAnne and an important relationship in her social network is weak, and there is a lack of fit between needed environmental resources and her personal resources to deal with her boyfriend. Here is another example to further illustrate the application of life-modeled assessment. Summarized samples of individual, family, and group assessments are presented in appendix A. Case Illustration: Person:Environment Fit. Mrs. Rivera, a 75-year-old widow, has suffered a stroke. As a result, she is confined—most likely permanently—to a wheelchair.

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Based upon available theory and research on the physical, social, and psychological consequences of stroke, we can assume that this life transition will create stress for Mrs. Rivera. She has abruptly gone from being able-bodied to wheelchair-bound. How much stress and difficulty she will experience as she accommodates her new status will depend upon a number of factors: her preexisting and current physical condition (extent of physical loss, stamina, and fitness); personal resources (motivation, outlook on life, coping skills, how she experiences her illness, and self-efficacy); access to formal organizational resources (medical and nursing care, physical rehabilitation, and homemaker assistance); availability of social support networks (family, relatives, friends, and neighbors); supportive physical environment (wheelchair accessibility of her building and apartment); and financial resources.

The medical social worker responsible for discharging Mrs. Rivera from the hospital will have a different set of responsibilities depending upon what her assessment of Mrs. Rivera’s level of fit reveals. Let us examine several different possibilities next.

SCENARIO 1

1. Mrs. Rivera is a hardy, resilient individual. She has experienced previous hardships in her life, including the death of her spouse and a child, and has bounced back and developed better coping skills as a result. 2. Mrs. Rivera is Mexican, and within her culture, commitment to family is paramount. She has a strong support system, in the form of adult children who are prepared to care for her until a permanent care plan is established. Upon discharge, she will move in with them as she receives physical therapy. 3. She has the financial means to allow her to secure any resources she may need. The plan will be for her to return home when ready and receive the assistance of a home health aide for as long as necessary. 4. Mrs. Rivera has a strong social network, in the form of friends and extended family members, which provides her with social and recreational opportunities. She attends a senior center three times a week and an exercise class once a week. 5. Mrs. Rivera attends church regularly. In this scenario, Mrs. Rivera’s environmental and personal resources are strong. Although she is facing a stressful life transition, her environmental and

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personal resources are likely to serve as important protective factors. The social worker’s intervention would emphasize identifying and linking Mrs. Rivera to new resources that she will need upon discharge, as well as ensuring that she stays connected to resources that she already is using. The worker also may need to provide emotional support to help Mrs. Rivera and her family transition to her “new normal” as a disabled individual. This might include educating her and her children about self-care and living a full life after a stroke. Mrs. Rivera may also need help with grieving the loss of her mobility.

SCENARIO 2

1. Mrs. Rivera has been chronically depressed and is in poor physical condition due to lack of activity; both conditions predate the stroke. 2. Her husband died suddenly of a heart attack six months ago, a loss that she is still grieving. 3. Due to her physical and mental health problems and her grief, she has withdrawn from her social network and has been more or less isolated for the last six months. 4. Mrs. Rivera has two adult children, but they live in Mexico, the country from which she emigrated 30 years ago. Although the Riveras have close family ties, her children are unable to come to the United States to assist her due to financial limitations, work and family commitments, and immigration challenges. 5. Mrs. Rivera worked for many years cleaning houses and did not have any job benefits. She receives minimal monthly Social Security checks as a result of her husband’s employment as a janitor for a public school system. 6. She has health insurance through Medicare, but she does not have sufficient income to purchase insurance to pay for what Medicare does not cover. 7. Upon discharge, Mrs. Rivera will be unable to return home, since she cannot perform basic activities of daily living. Due to her limited finances, there are limited options for her care. In this scenario, Mrs. Rivera’s personal and environmental resources are quite limited. Therefore, the stroke is a life transition that is likely to be very stressful for her, leaving her at serious risk of disorientation and further deterioration in her functioning. Emphasis will be on providing Mrs. Rivera with much-needed emotional support to help her adapt to her new status as a

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disabled individual. The worker also will need to help Mrs. Rivera create and/or revive a social network to provide support and assistance to her once the worker is no longer involved with her case. This includes exploring ways in which Mrs. Rivera can stay connected to her children in Mexico. The worker also will have to identify and connect Mrs. Rivera with resources that can help her remain and participate in her community. This should include an evaluation of the possible neurobiochemical causes of her depression. These two scenarios represent opposite ends of a continuum. In reality, we are most likely to encounter clients whose challenges and resources to overcome them lie somewhere between these two extremes. In Mrs. Rivera’s case—as with all clients—workers must keep in mind that their assessments are only as good as the information they collect. Accuracy depends upon three important considerations. First, the worker must operate from a culturally competent and diversitysensitive perspective in order to avoid barriers that result from worker-client differences. In this case, relevant issues depend upon the identity and status of both Mrs. Rivera and the worker. Cultural identity, age, socioeconomic status, and disability are likely to be important, given what we know about Mrs. Rivera. Other factors will be important depending upon the worker’s status and identity. Let us assume that the medical social worker is a white man who is 40 years younger than Mrs. Rivera. In this case, gender may be an issue, and age may take on particular significance. In contrast, if the medical social worker is a 60-year-old Latina, cultural identity, age, and gender may take on significance in a different way. Obvious similarities between the worker and client, if not acknowledged and addressed, might actually mask differences that could undermine the worker’s efforts to be helpful. Second, the worker is tentative when using relevant theory and research to understand a client situation. Prior knowledge informs the direction of the worker’s questions and the assessment that she or he develops. However, the worker must ask for feedback from the client. Workers check in regularly with their clients to make sure that they are on the right track, understand what clients are telling them, and the like. They will need to use skills that we describe in chapter eight, including rephrasing, acknowledging and verbalizing feelings, clarifying indirect communication, and reaching for specific feelings. Also, as the worker explains agency function and her or his professional role, she or he is assisting the client in providing information that helps both develop a plan of work. These skills and others are part of the process of assessment. A final aspect of the life-modeled assessment process is the emphasis on moment-to-moment. In any helping encounter, the worker faces an array of simultaneous issues and varied cues. The practitioner must determine which

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ones to respond to, which to ignore, and which to put aside for later consideration. There is little time to think about a “correct” intervention. Conceptualizing life issues and stressors as difficult life transitions and traumatic life events, environmental pressures, and maladaptive family and group processes provides a framework for moment-to-moment assessment. To illustrate this point, we return to Mrs. Rivera. At an early point in the second and final session with Mrs. Rivera prior to her discharge, she complains to the worker about her loneliness and isolation (scenario 2). Because Mrs. Rivera’s social situation and mental health can either support or undermine her transition back into the community and recovery, the social worker needs to obtain additional information about this disclosure. The worker can ask something like, “Can you tell me more about that?” in order to determine with Mrs. Rivera whether at this particular moment she is asking for help with either or all of the following issues: • Exploring her grief and requesting help with mourning her loss of physical mobility and independence and her husband (seeking help with a life transition) • Exploring her feeling of social isolation from her friends and family and asking for help with reaching out to natural support systems or constructing new support systems (seeking help with the environment) • Indirectly complaining about the worker’s inattentiveness or lack of understanding and asking that they focus on their interactions with one another, or both

These options are not mutually exclusive. From one moment to another, the focus may change, challenging the worker’s ability to sensitively and skillfully assess and follow Mrs. Rivera’s cues. This ability and the skills that are required are key to the process of assessment. Emphasis on Assessment of Clients’ Strengths

Another essential feature of life-modeled assessment is identifying individual, family, group, and community strengths. In theory, this is straightforward, but in practice, it is often very difficult to accomplish. When our clients come to us, or we reach out to them, they are likely to be primed to talk about their problems, their stressors, and everything that is going wrong. When clients are mandated to see us, the only problem they may identify is us, and the requirement that they have to see us. Whether they seek, are offered, or are mandated to receive our services, clients do not expect us to ask them about their strengths and often have a difficult time identifying them. We can certainly ask clients, “What would you identify

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as your strengths?” or some variation of this. In some agency settings, as part of the intake process when the worker is collecting information on the client, this is a standard question. However, the question may not lead to useful information, since most clients are likely to draw a blank. If our assessments are to be balanced and useful, we must find a way to obtain this information as well as understanding clients’ difficulties. Solution-focused questions can help us assess and mobilize clients’ strengths to deal with their life stressors (Berg & DeJong, 2008; deShazer, 1988). The solution-focused model provides two questions that can help clients identify strengths that they—and their worker—might otherwise overlook. When workers ask about exceptions, they are asking clients to think about times when they were managing their stressors better and were more successful in living their lives. The assumption that underlies this question is that solutions to clients’ current life stressors lie in how they have managed past challenges (Knight, 2004). The worker and client search for exceptions to the life stressors. This information can be useful in developing our assessments and managing current (and future) stressors. This question can take many forms, but at its simplest, the worker is asking, “How did you do that?” “How did you make life better/manage stress/deal with your challenges?” The emphasis is on what the client did to improve the situation. The implication is that the client is resilient and has the capacity to manage current and future challenges. The following example comes from one coauthor’s practice with a group for adult survivors of sexual abuse. In this intake interview, the worker not only collected information about the stressors that Rose currently was facing, but also helped her identify successful attempts to cope in the past. Rose, 28, was referred to the coauthor after being released from an inpatient psychiatric facility. Her stay in the hospital was necessitated by a life-threatening escalation in her eating disorder, a common problem among survivors of sexual abuse. rose: Well, over the last eight years, I’ve been hospitalized 12 times! My anorexia gets so bad, they have to put me in the hospital. worker: Wow, that has to have been tough. But let me ask you something. You’ve been hospitalized a lot, but it strikes me that you have been out of the hospital more than you have been in. How did you do that? How did you keep yourself out of the hospital? rose: I don’t know. Never thought about it. worker: Well, I think we should try to answer that question. Because you did, right? You kept yourself out of the hospital.

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rose: Well, actually, I always get discharged because the money runs out. worker: Okay, so you might not have felt ready to leave, right? rose: (Nods) worker: But, you stayed out, even though you didn’t feel ready. That takes a lot of strength! How did you do that? rose: (Hesitates). Well, I got back into my running, which helps me with stress. (Hesitates) I journaled, and I went back to my volunteer work at the animal shelter. worker: Okay, so now we know about three things that you did to manage your stress which could help you stay out of the hospital. You can exercise, you can journal, and you can volunteer your time to help others.

This part of the session has been condensed for the sake of brevity. In fact, it took quite a bit of time and persistence to help Rose identify strengths that she already possessed but did not know she had. Clients are primed and prepared to talk about their problems. They often need help in identifying their strengths. In this excerpt, Rose’s answers were reframed by the coauthor as ways of coping and managing stress. As she begins to see this, she can learn, with the worker and the group’s assistance, how to use these behaviors more intentionally to deal with future challenges. Coping questions are designed to elicit strengths in those situations when clients are so overwhelmed with life stressors that identifying past exceptions would be too difficult. In its basic form, the worker asks, “Given how tough things are for you right now, how are managing to cope?” As with asking about exceptions, clients typically have difficulty answering this question. And, consistent with asking about exceptions, they are likely to respond with “I don’t know.” The setting of this next excerpt is shock trauma in an inner-city hospital. The social work student is providing individual crisis counseling to individuals who have lost a loved one to gun violence. Allen’s contacts with clients are usually very brief. He typically is able to see clients only at the time when they or their loved ones are being cared for in the hospital’s emergency room. Once that care ends, so does his involvement with his clients. Allen is meeting for the first and only time with Ms. Johnson, whose 15-year-old son was shot and killed by a rival gang member. Ms. Johnson is highly distraught and crying uncontrollably. allen: Ms. Johnson, I am so very sorry. Losing a child is the hardest thing for a parent. ms. johnson: (Crying) allen: (Reaches out and touches her hand). It’s hard. . . .

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ms. johnson: My baby, my baby. I ain’t got nothing. He was my baby. My boy. allen: I can’t imagine how much pain you are in. It’s devastating.(Silence) allen: But somehow you are still standing. Despite all the pain, you are still here, putting one foot in front of the other. How are you doing that? ms. johnson: I ain’t doing it. I’m done, spent, wore out. allen: But somehow, you got yourself to our appointment today. How did you do that? ms. johnson: (Silently crying) allen: Despite the sadness, despite the pain, you’re here. How did you do that? ms. johnson: I don’t know. I don’t know. I just got up, I ate my breakfast, I got on the bus, and I came here. I just did it. I had to do it. allen: Well, actually, you didn’t have to do this, but you did. You kinda put your feelings in a box, and that helped you get here, where you can get the help you need.

Again, we have shortened this exchange. Allen’s field placement is particularly challenging. His clients are usually quite distraught, having experienced a sudden and usually violent loss of a loved one. Depending upon the circumstances of the case, he usually has only one brief encounter with a client. Allen provides the client with immediate support but then must refer the client elsewhere for follow-up care. Allen did not ignore Ms. Johnson’s grief, but his focus was on identifying a way of managing her feelings that would allow her to get the help that she desperately needed. He balanced empathy with helping Ms. Johnson to see what she was doing to get herself through the pain of losing her son. He reframes Ms. Johnson compartmentalizing her feelings as a strength. As she moves through the phases of grief, she will need help expressing and working through her feelings. To do this, she will have to learn to consciously “put them in a box” to make them more manageable. Allen’s intention here was to identify for Ms. Johnson strengths that she was already using and that she would need to call upon in the future. Assessing Clients’ Motivation to Address Life-Transitional Stressors

One of the most challenging aspects of our profession is engaging clients in a working relationship who are ambivalent about or do not seem to want our help. Sometimes a client may appear to be “resistant, hostile, and unmotivated.” However, this behavior may reflect a lack of hope and overwhelming despair. There are many reasons why clients are reluctant to engage with us. Most

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fundamentally, many believe that alleviation of their life stressors is not possible or that they are not capable of dealing with the life transition they face. Many clients simply are not ready for the help that we offer or that they are required to take. Therefore, a critical aspect of assessment is determining the degree to which clients are motivated to address the challenges they face. Individuals often move through different stages of change (Prochaska & DiClemente, 1984; Prochaska, Norcross, & DiClemente, 1995): • Precontemplation: “I don’t have a problem. Everybody else does.” • Contemplation: “Well, maybe I do have a problem.” • Determination: “Yep, there’s a problem. Now what do I do?” • Action: “I need to take the following steps to address the problem.” • Maintenance: “What must I do to keep moving forward?” • Relapse: “Oh no, I fell back into my old ways of behaving!”

Rather than being fixed and linear, it is best to view these stages as fluid phases influenced by external forces and changes in the client’s readiness for change (Gitterman & Heller, 2011). Using this formulation, social workers assess clients’ level of motivation and, when necessary, assist them in moving forward. In many situations, our earliest intervention with clients may focus on enhancing their motivation to accept our help. In subsequent chapters, we will discuss the skills needed to do this. The mistake that many of us—as well as the agencies for which we work— make is assuming that our clients are in the “determination” phase, when they really are in the first or second phase; they have yet to accept there is a life stressor that they must (or can) do something about. A solution-focused question, the miracle question, meets clients where they are, addressing their lack of motivation directly. This is referred to as coconstructing cooperation (DeJong & Cronkright, 2011; Oliver & Charles, 2015). In its simplest form, the worker asks a mandated or reluctant client, “Imagine you wake up tomorrow and a miracle happens and you don’t have to work with me anymore. What would that look like? What would have to happen for the agency to be able to close your case?” When the worker poses the question in this way, she is conveying to clients, “I get it. You don’t want my help; you don’t think you have a problem. I am the only problem you have.” The worker joins clients in seeing the situation as they see it. This increases the likelihood that clients will join with the worker in a genuine effort to make changes rather than going through the motions just to satisfy the mandate.

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Consider the following example. Charlene is placed in a public child welfare agency in a family preservation program. The goal of her work is to support families at risk of losing their children to foster care due to abuse and neglect. For a class assignment, she writes about her work with one family, the Palmers. Ms. Palmer was found to have neglected her children. She would frequently leave her young children home alone while she went in search of drugs or partied with friends. When home, she often slept, leaving her children to care for themselves. Ms. Palmer has signed a “contract” with the agency in which she agreed to take certain actions, such as attending Narcotics Anonymous meetings and a parent support group, as a condition of maintaining custody of her children. Charlene writes: Mom knows she has to do these things. Otherwise we’re going to take her children. But I realize now that these tasks are important not because the mom says they are, but because we say they are, since they affect the well-being of her children and that’s our job. Maybe she feels like she has lost control in her life and that everyone is making plans for her and her children. Maybe she is just trying to place the blame elsewhere because she feels like she is being blamed. This mom has a lot going for her—she’s intelligent, resourceful, and she loves her children. She’s more than able to do the things that need to be done. She just won’t do them! I began our next session with Ms. Palmer by telling her that it was clear that she really loved her children, but I was puzzled because there were times when she hadn’t been able to do what was necessary to keep her children with her. I asked if maybe she sometimes got pissed off at being told what to do. At first, she shook her head no, but then she said, “I just wish you all would leave me alone.” I told her that I could understand that it must be hard not to be able to always make your own decisions about your kids, that this might make you feel like a kid yourself. She agreed. I asked her to tell me what it would be like if we really did get out of her life, if we really did let her be. What would that be like? She got excited and started talking about how it would just be her and her two kids. I said, “You know the agency got involved with your family because there were signs that Sean and Katy [mom’s children] had been neglected and we felt that you needed support and help. Describe what things would look like if we were to say to you, ‘Okay—we’re done. You’re doing great! We’re outta here!’ How would I know that things were all better for you?” She replied, “I would be keeping appointments and following through on recommendations from the kids’ school and counselors, I would be properly supervising them, and I would be clean.” I asked her to think about how she would get to that place that she just described. I also suggested that we identify steps that she already had taken to get there, and how we could keep her moving forward.

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Charlene and the agency assumed that her client was in the action stage when she was most likely only in the contemplation or determination stage. Charlene initially made the mistake of assuming that her agency’s goals for her client were the same as the client’s goals for herself. Ms. Palmer may have understood that she had to work with the student social worker, but she was not invested in the work. In many agencies, this problem is compounded by the “contracts” or “service plans” that clients must sign. In too many instances, the client signs a plan of work with no commitment to doing the work. The requirement that Ms. Palmer work with the agency may have pushed her into contemplation, or even determination. Even at this stage, though, she may have continued to believe that the problem was the agency. When we consider the miracle question from the stages of change concept, this question helped Charlene start where the client was, framing the problem in a way that made sense to Ms. Palmer, and encouraged her—through identifying aspects of her miracle scenario—to progress to the acceptance stage and on to the action stage. In asking the mother to imagine a future without the agency in the picture, the worker was offering her a chance to take control of her life and get what she wanted: freedom from the agency’s interference. If we are going to help involuntary clients become voluntary ones, we must be able to accurately assess their levels of motivation. Earlier in this chapter, we introduced skills that assist with developing an accurate assessment. Two of these—clarifying indirect communication and reaching for specific feelings—help the social worker determine clients’ level of motivation. Rarely will clients be able to answer a direct question about how motivated they are. They either do not know the answer or they will say what they think we want to hear. Therefore, we must rely upon our active listening skills, which allow us to tune in to and respond to what they are telling us nonverbally and indirectly. It was only when Charlene “listened” to what Ms. Palmer was indirectly telling her by not following through on the tasks that she was required to do that she was willing and ready to do the work. Although they had met for several sessions prior to the one Charlene describes, it was the session in which she introduced the miracle question that their work really began. Readers no doubt noticed that the last stage is relapse, or regression. An important aspect of being in the world of “is” is recognizing that the process of adaptation is uneven; clients move ahead several steps and then fall back, move ahead a few more, and may fall back again. Relapses or regressions are not failures, though clients are likely to view them this way. Relapses provide both worker and client with valuable information about what went wrong and what

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Table 5.1 Tasks and Considerations Associated with Life-Modeled Assessment Collecting salient information

Nature and severity of clients’ life stressors; clients’ perception of and responses to stressors; clients’ expectations of both the worker and the agency; clients’ strengths and limitations; relevant environmental resources and gaps

Organizing information

Identify significant patterns; clarify clients’ adaptive balance or imbalance; reveal the level of person:environment fit; provide direction for worker and client collaboration

Analyzing and synthesizing information

Draw inferences using inductive and deductive reasoning to determine clients’ strengths and limitations, environmental resources and deficits, and the level of fit

Active listening

Attend to clients’ verbal and nonverbal and direct and indirect communication to determine meaning

Attend to the meaning of cultural differences and clients’ identities



Maximize client participation



Moment-to-moment assessment



Identify client strengths

Asking solution-focused questions: identify exceptions to problems and coping questions

Assess clients’ motivation

Use the stages of change model to determine clients’ motivation to address the challenges they face; coconstructing cooperation with mandated clients

went right. In our discussion of the work phase with various client groups in subsequent chapters, we will cover this in more detail. At this point, we simply note that when a client goes backward, instead of focusing solely on why, the worker can ask clients to think about exceptions: how did they keep moving forward before the relapse? Armed with this information, the worker can help clients learn from sliding backward so they can move forward once again. Table 5.1 summarizes tasks and skills associated with life-modeled assessment. Using Visual Assessments

In most instances, social workers present the results of their assessment—the product—in the form of a written narrative or summary of the information that

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has been collected, their observations, and their interpretation of what the information means. These narratives include case histories, intake and discharge summaries, and progress or case notes. Graphic representations complement written narratives and provide a visual “snapshot” of clients’ interactions with their social environment and their capacities to deal with stressors and change dysfunctional patterns of dealing with life stressors. An ecomap helps us visually grasp the complexity of clients’ environments and the multiple transactions that are involved (Hartman, 1978; Hartman and Laird, 1983). Developing an ecomap has been streamlined using computer technology (Gustavsson & MacEachron, 2013; Young, 2015). The following sites provide social workers with downloadable mapping templates: https://mswcareers.com/the-ecomap-a-social-work-assessment-tool/ and https://creately.com /blog/diagrams/social-work-assessment-tools-templates/. The advantage of developing a visual representation of clients’ transactions with their environment is readily apparent in the ecomap in Figure 5.1 depicting the two scenarios outlined in Mrs. Rivera’s case. We used the template from the creately website.

Scenario 1: Strong Environmental Resources

Scenario 2: Limited Environmental Resources

Cultural Heritage

Adult Children in Mexico

Adult Children

Financial Resources Mrs. Rivera

Senior Day Program

Friends

Extended Family

Extended Family

Limited Income Mrs. Rivera Limited Health Insurance

Friends

Church

Key: Strong Relationship Weak/Nonexistent Relationship Stressful Relationship

Figure 5.1 Comparison of two Ecomaps: Mrs. Rivera

Social/ Recreational Outlets

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The genogram is an intervention tool developed for social work practice by Hartman (1978, 1979, 1983). A genogram is a family tree that incorporates major family events, occupations, losses, migrations and dispersals, identifications, role assignments, alignments, and communications patterns across two or more generations (McGoldrick, Gerson, & Petry, 2008). It also brings to the foreground how family aspirations, myths, secrets, expectations, and perceptions are transmitted from one generation to another. Family genograms are available for download at https://www.genopro.com/genogram/templates/. An ecomap is a tool that typically is used only by social workers, and at times their supervisors. A genogram is often used with clients as a way of pointing out intergenerational patterns and inherited traits (Pope & Jacquelyn, 2015). Research findings suggest that a visual representation of a family history of behavioral and mental health problems like substance abuse and depression can be an effective way of helping clients acknowledge current problems that reflect family behavioral patterns and genetics (Goodman, 2013; Newman, Burbach, & Reibstein, 2013).

EVIDENCE-GUIDED PRACTICE Practice Monitoring

Our professional task is to turn knowledge and self-reflection into personalized interventions. We must be creative in monitoring the connectedness of our interventions to clients’ messages and evaluating our clients’ progress and the outcomes of our work together. The effectiveness of our work with clients begins with awareness of ourselves as we practice. Therefore, assessing the impact of our work with clients begins with monitoring ourselves. Two practice instruments, the Record of Service and the Critical Incident Analysis, are extremely helpful in the monitoring of professional practice.1 They allow workers to evaluate the extent to which their interventions are connecting with what their clients are asking for help with at any particular moment in time. In other words, these tools allow us to evaluate the effectiveness of the process of our efforts to be helpful. The Record of Service traces in depth a worker’s efforts to help an individual, family, group, or community with a specific life stressor. A life stressor is conceptualized; the client’s views of the stressor are identified; the degree of fit between the client and the environmental strengths and limitations for dealing with the life stressor is assessed; the specific helping interventions are conceptualized and

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evaluated; the progress (or lack thereof) in the work is analyzed; and specific next steps are defined. The worker draws on the theoretical and research literature with respect to the specific stressor and applies relevant concept and research findings. A sample Record of Service is presented in appendix B. The Critical Incident instrument helps practitioners examine in depth one incident that has taken place during the helping process. It can be used in work with all client groups and in organizational interventions. A critical incident consists of 8 to 12 consecutive transactions, beginning with a client’s responses. Each intervention, including purposeful nonverbal gestures and silence, is underlined and numbered. A critical incident represents a microcosm of themes in the worker’s practice, and it can be generalized beyond the particular incident and the particular case. The emphasis is on enhancing practitioners’ ability to maintain a continuing process of moment-to-moment assessment and relating their interventions to their understanding of clients’ verbal and nonverbal and direct and indirect communication. The critical incident analysis requires application of pertinent theory, knowledge, research, practice concepts and principles, and consideration of values and ethical issues. Appendix C presents two samples of critical incident analysis, each with a slightly different emphasis. The first summarizes an analysis of individual transactions; the second presents an analysis of the total incident.

PRACTICE EVALUATION Linking the Assessment Process to the Evaluation of Outcomes

Social work practice research and its contributions to our professional knowledge base emerged from diverse traditions. Three basic approaches to evaluating practice interventions exist. In the case study method, intervention hypotheses are assessed through detailed documentation of practice. This method is grounded in the processes and details of a case and captures the subtle nuances of practice. The worker also functions as the “researcher” but is not a neutral observer and may overestimate practice “successes.’’ The findings from a particular case, in a particular setting and context, may be overgeneralized and inappropriately applied to other clients, settings, and cultures. Therefore, the validity and the reliability of the worker’s observations represent a critical limitation of the case study method. In the group comparison method, two groups composed of people with similar backgrounds and characteristics are established. An intervention (known as

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the independent variable) is provided to one group (known as the experimental group) and withheld from the other (known as the control group). By measuring the differences between the groups on an outcome measure (the dependent variable), the effectiveness of the intervention on the individuals in the experimental group can be determined. Validity and reliability are more effectively established in the group comparison approach than in the case study approach due to the use of the control group. Group comparisons, however, also have significant disadvantages. The impact of an intervention is evaluated on the experimental group as a whole, not on any of the individuals it includes. Thus, the individual response is lost in the aggregated data. Neither the case study nor the group comparison method adequately accounts for the impact of the environment and other factors that could influence outcomes. A new job or a sudden loss of a relationship may have a more profound positive or negative effect than the professional intervention itself. Further, interventions usually are defined ambiguously. Even when interventions are clearly specified, they are evaluated on their own terms, as if they were separate from a worker’s style and persona. The art of social work practice is removed from its science. Individual practitioner skills and the reciprocal transactions between social workers and clients are often ignored. The single-subject design method represents a more rigorous elaboration of the case-study approach and a return of focus from the group to the individual client. This design is widely used in large-scale research, but it also can be readily adapted by the individual social workers to assess the outcome of their work. When applied to individual social workers’ practices, the single-subject design relies upon information—data—derived from their actual work with clients. When clients are actively involved in defining their life stressors, identifying desired outcomes, and participating in the interventions, they become engaged in evaluating their own progress (Faulkner & Faulkner, 2009; Sheafor, 2011). The standard protocol for the single-subject design method consists of two phases. Phase A requires the establishment of a baseline: the measure of clients’ behavior, perception, attitude, feelings, and/or other relevant characteristic prior to any intervention. Phase B is the introduction of the intervention. When feasible, the same client behavior, perception, attitude, feelings, and/or other relevant characteristics are assessed at various points during this phase. At the conclusion of the intervention, the behavior, perception, attitude, feelings, and/or other relevant characteristic are measured again. From a purely research standpoint, the establishment of a baseline measures the dependent variable prior to the introduction of the worker’s involvement, which is the independent variable.

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During the course of the intervention and at its conclusion, changes in the dependent variable are measured, and any changes that are observed are assumed to be the result of the intervention. The possibility that these changes are due to factors other than the intervention is lessened, but not eliminated, since clients serve as their own controls. Ideally, baseline data are collected at various points in time. If only collected once, the measure may not be representative of clients’ typical functioning. In reality, practical and ethical considerations often prevent us from being able to ascertain client functioning at more than one point prior to our intervention. From a straightforward research perspective, four dimensions of the intervention (the independent variable) itself can be measured: form, content, dosage, and context (Nelsen, 1985, 1988). Form refers to the nature of the intervention, such as solution-focused questioning. Content refers to the message provided by the intervention. Asking the miracle question and asking about exceptions would be examples of content. How extensively and intensively interventions are repeated reflects dosage. Many social work interventions are conducted weekly, while others, like intensive family intervention in child welfare, might involve contact several times a week, or even daily. These would reflect differences in dosage. Context refers to such factors as the client’s prior experiences with professional and social service agencies, the worker’s and client’s reactions to one another, the degree of trust and conditions of safety established in the helping relationship, the degree of client choice, and messages communicated in voice tone and nonverbal behavior. Context includes many of the factors that make up the artistry of social work. Ideally, we are able to specify or quantify each of these four dimensions. However, in the real world of social work practice, this is not always possible or practical. In its simplest form, the application of a single-subject design might look something like this: The social worker, Brad, a 38-year-old white man, is employed in an outpatient mental health clinic and has a first interview with Nadine, a 22-year-old woman who identifies herself as African American struggling with stress and anxiety. She reports symptoms such as difficulty sleeping and eating, uncontrollable crying, and isolating herself from others. Brad establishes a baseline (phase A) by asking Nadine to do the following: • Estimate at two points in time—as they start their session and in the past week—to rank how stressed she is on a scale of 1 to 10, with 10 being the most stressed she

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has ever been and 1 being the least stressed (this solution-focused scaling question is also known as a self-anchored rating) • Complete a rapid assessment instrument (RAI) that measures her current level of stress After Brad collects relevant background information from Nadine, they agree that her stress may be the result of her current work situation. She is not making enough money to support herself and her three children. Further, she reports that she is being sexually harassed by a male colleague. They agree to • Meet weekly for a defined period of time • Focus on helping Nadine create a résumé, begin a job search, initiate a complaint against her coworker, and develop stress management techniques (phase B) Each week and after the 10th session, Brad asks Nadine the scaling question about her stress level, and after their 5th session and at the conclusion of their work in the 10th session, he once again asks her to complete the RAI, which measures stress. The intervention (independent variable) includes the following: • Form: Life-modeled practice • Content: Life-modeled practice skills, solution-focused and cognitive behavioral strategies • Dosage: Weekly meetings of one hour for 10 weeks • Context: Cultural differences, barriers to change in Nadine’s environment, Brad’s level of skill, quality of the working relationship between Brad and Nadine

Ideally, when she terminates her work with Brad, Nadine’s self-anchored rating of her stress level will be lower than it was when she began, and her score on the RAI also will show a reduction in stress. Even if this is the case, though, once Nadine terminates with Brad, he has no way of knowing whether the gains she made at the end of their work will be sustained over time. His position does not allow him to follow up with her to determine this. The reality is that the helping process is rarely as linear and straightforward as laid out in this scenario. Factors other than our intervention efforts may confound or account for the actual outcome (Macgowan & Wong, 2014; Sheafor, 2011). A major confounding factor is a change in the client’s environment. For example, Nadine’s coworker might leave his job, which could have a direct, positive impact on her stress level. In fact, this environmental change may have been

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more responsible for her improvement than the helping intervention. Another factor is the client’s preexisting coping capacities. Nadine may, by nature, be a resilient individual who, with little prompting from Brad, is able to make the changes necessary to reduce her stress level. The treatment environment itself may have its own built-in confounding factors. For example, Brad’s unconditional support and validation of Nadine’s concerns may be the primary source of the improvement in her stress level, rather than his using any of the specific techniques. Finally, it is extremely difficult to ensure that the intervention that is conceptualized is actually utilized. Brad may intend to use skills drawn from life-modeled practice, as well as those associated with particular models like solution-focused and cognitive-behavioral. Whether he actually does this is unclear. Without the safeguard of external verification by independent observation, the specified intervention may be delivered in a manner other than what is intended. Life-modeled practice integrates a number of practice frameworks and perspectives as a way of responding to the unique needs of each client. It is not a single method that relies upon a prescribed set of skills. As stated in chapter one, a predetermined, mechanistic approach to practice is the antithesis of life-modeled practice, but it would make single-subject evaluation more straightforward. Using Assessment to Evaluate Practice Outcomes

Even with the challenges that we have noted, the information collected in the course of our assessments of clients provides us with the tools we need to evaluate our practice efforts. To illustrate this process, we will use the case of Esther, a client of one of the coauthor’s. We will return in later chapters to the steps described here, particularly establishing goals and objectives and developing a mutual plan for work, or contract. At this point, our emphasis is on how the worker can use information collected from the client to establish a means of evaluating effectiveness. Esther, age 25, was sexually abused by a teenage neighbor when she was approximately 5 to 8 years of age. She recalled the abuse spontaneously, with no warning. She told a close friend (a former student of the coauthor), who suggested she call her. In the initial assessment, Esther, who herself was in the mental health field, identified her extreme stress and anxiety at what she had remembered as her primary concern. She also understood that she would need to address what she

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had remembered, but she believed that her most immediate need was to manage her anxiety. When the author asked her a version of the miracle question, she initially said with a smile, “That what I remembered hadn’t happened!” She then envisioned a scenario in which she was no longer stressed, was once again sleeping, could concentrate at work, and could reconnect with friends from whom she had isolated herself. More in the long term, Esther envisioned a life where she understood and accepted what happened to her as a child and moved past it. Using this information, the worker and client agreed to the following: Overall hoped-for outcome: Esther will come to terms with and manage her feelings about what happened to her. Beginning objectives (where to start): • Esther will feel safe, and more “in control.” • Esther will feel less stressed. Tasks (what the worker and client will do to achieve these objectives): • Esther and I will identify sources of comfort and ways to help her relax using solution-focused questioning about exceptions to problems and ways of coping. • Esther will practice techniques at home and provide feedback as to their effectiveness. • Esther and I will begin to discuss what happened to her, focusing initially on helping her understand the dynamics of sexual abuse and its impact on its victims.

The author’s work with Esther typifies the nature of many of our interventions with clients. The worker and client identified both her immediate needs and the tasks associated with meeting them, as well as what she wanted to see happen over the long term. Using this case illustration, we can identify different approaches—which are not mutually exclusive—that could be used to measure the outcome of our initial efforts: Single-subject design: Esther provides a self-anchored rating of her level of stress at the beginning of the work to establish a baseline: “On a scale of 1 to 10, with 10 being the most stressed you have ever been, how stressed are you right now?” Each week, Esther rates her level of stress. Alternatively, or in addition to this, the worker could ask Esther to complete a short RAI that assesses her level of stress, as at the beginning of the work. The worker could then ask her to complete the questionnaire at

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some point during the work, and again at the end. Many such scales exist. One of the simplest and most widely used is the Perceived Stress Scale (http://www.mindgarden .com/documents/PerceivedStressScale.pdf). Task achievement scaling: The worker and Esther assess her progress toward the tasks that they have identified. For example, we would assess how much progress she has made on the task of making herself feel safe. This would be done during and at the end of the work. The worker and Esther would determine the indicators of achievement. Such a scale might be as follows:

4: Completely achieved. Esther uses these techniques consistently and feels safer when she does. 3: Substantially achieved. Esther uses these techniques some of the time and feels safer when she does. 2: Partially achieved. Esther uses these techniques some of the time but still feels unsafe. 1: Minimally achieved. Esther has identified techniques but has not used them. 0: No progress. Esther has not identified nor utilized any techniques Goal attainment scaling: Periodically, the worker and Esther evaluate her progress toward her initial objective of feeling more in control. Consistent with task achievement scaling, the following indicators of attainment are identified:

+2: Best anticipated. Esther feels in control of her feelings all the time. +1: Better than expected. Esther feels in control of her feelings most of the time. +0: Expected. Esther feels in control some of the time. –1: Less than expected. Esther feels out of control some of the time. –2: Most unfavorable. Esther feels out of control most of the time. In addition to providing us with ways to evaluate the effectiveness of our work, these strategies provide three advantages. First, they are empowering to clients and maximize their involvement in the process of change. Second, they reflect the life-modeled view that clients are the experts in their lives. Third, when we utilize these strategies during our work, not just at its conclusion, we can monitor our progress and make changes and adjustments and change course, if necessary.

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Despite these advantages, we must use caution when interpreting the results of our evaluation efforts. The main drawback of the single-subject design is that it cannot account for all the forces that exist in clients’ environments that influence their progress (or lack thereof). Goal attainment and task achievement scaling are inherently subjective, depending upon workers’ and clients’ perceptions of indicators of success, and therefore may be influenced by bias. Further, many clients’ challenges are hard to quantify using scaling of best- and worst-case scenarios. Finally, none of these approaches capture the critical but hard-to-capture role that the unique working relationship between worker and client plays in explaining client outcomes. It is for this reason that the Critical Incident and Record of Service forms should be part of any efforts we undertake to assess our effectiveness. Table 5.2 summarizes approaches to evaluation based upon client assessment. Practice Considerations Associated with the Use of Rapid Assessment Instruments

RAIs are used in both clinical practice and research. Typically, they are brief questionnaires completed on paper. Some are unidimensional (i.e., they measure one attribute), while others are multidimensional (i.e., they measure several aspects of functioning). Examples of the former that are widely used in practice with adults (and adolescents, in some cases) include the Beck Depression and Anxiety

Table 5.2 Using Assessment to Evaluate Practice Establishing goals and objectives

Use of the miracle question to identify short- and longterm goals and steps needed to achieve them

Single-subject design

Worker and client establish a baseline using self-anchored rating, the rapid assessment tool (RAI), and scaling questions, and monitor client progress over time and at the conclusion of the intervention

Task achievement scaling

Worker and client, when able, determine indicators of task achievement using a 5-point scale (ranging from “Completely achieved” to “No progress”) and evaluate outcome

Goal attainment scaling

Worker and client, when able, determine indicators of goal attainment using a 5-point scale (ranging from “Best anticipated” to “Most unfavorable”) and evaluate outcome

Client satisfaction survey

The agency and/or worker asks the client to evaluate satisfaction with services

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Inventories (http://www.pearsonclinical.com/psychology/products/100000776 /beck-family-of-assessments.html#tab-scoring) and the Addiction Severity Index (which includes an interview portion; https://pubs.niaaa.nih.gov/publications /assessingalcohol/InstrumentPDFs/04_ASI.pdf). Multidimensional instruments include the Global Severity Index and the Brief Symptom Inventory (http://www .pearsonclinical.com/psychology/products/100000450/brief-symptom-inventory -bsi.html). Rapid assessment tools also are available for children, families, and the aged. A good resource for social workers is Corcoran and Fischer’s Measures for Clinical Practice (2013). This two-volume reference includes descriptions of and information regarding hundreds of instruments for children, adolescents, adults, the aged, and families. Many of the available inventories have been used with large groups of individuals, resulting in norms against which individual clients’ scores can be compared. However, such comparisons should be viewed as suggestive of possible challenges that our clients may face and not as firm evidence (Abell, Springer, & Kamato, 2009). Consistent with a single-subject design, social workers can use RAIs to establish baselines for their clients and assess their progress over time. Workers should keep the following points in mind any time that they introduce a rapid assessment tool to clients: • Most require a certain level of literacy. • While some RAIs have been found to be culturally sensitive, many have not been evaluated on this dimension. • Clients are likely to view this as a “test.” Therefore, we need to clearly explain why we think it would be helpful and create an environment in which they feel comfortable answering the questions honestly. • Clients’ scores do not “prove” anything. They are suggestive of challenges that they may face. The social worker should always review the scores with clients and discuss what they may mean and secure their input. • The use of an RAI cannot replace collecting information from clients by talking to and observing them. The information that it provides complements the information derived from interviewing clients.

Practice Considerations Associated with the Use of Goal Attainment and Task Achievement Scaling

Goal attainment and task achievement scaling bridge the separation of process and outcomes by monitoring clients’ progress from two complementary

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perspectives. Clients are involved in specifying desired outcomes and the steps to achieve them. The worker and client partner together to develop scales to measure progress. Research suggests that the process of involving clients in goal-setting improves treatment outcomes (Kiresuk, Smith, & Cardillo, 2015). To ensure client success, the number of goals and the steps needed to achieve them should not exceed five at any one time. Goals and tasks need to be as clear and specific as possible and be stated in observable and measurable terms. They also should be realistic and achievable. The goals must be formulated as positive accomplishments rather than a reduction of negative behaviors. Achievable time frames also should be specified. As demonstrated in the case example of Esther, the worker and client establish possible outcomes of goal attainment and task achievement that identify progress or lack of progress. The middle point (0) in goal attainment scaling represents the expected outcome, while the end points (–2 and +2) represent the least favorable outcome and the most favorable outcome, respectively. The task achievement scale also includes different levels, with 0 indicating no progress and 1 through 4 indicating increasing levels of success achievement. While these are the typical scale indicators, the worker can decrease the number of outcomes, if this would be more manageable for and understandable to clients. By monitoring their own progress, clients are empowered to own the focus and direction of their work. The responsibility for change is in their hands. Achievable potential outcomes makes life’s difficulties seem more manageable and gives clients hope that situations can change. Experiencing progress motivates and mobilizes energy for further work. For workers, these scaling strategies provide similar advantages. Clients’ troubles seem less overwhelming, and a sense of direction and purpose is clear. Cautionary Notes

What we previously described in Esther’s case and in our subsequent discussion represents an ideal toward which we all must strive in our work. As the coauthor’s work with Esther progressed and concentrated more on the sexual abuse she experienced as a child, our ability to assess the outcome of our work became more challenging. Discrete tasks were harder to define. Esther’s overall goal—to come to terms with what happened to her and move forward—remained the same, but it became harder to identify objectives (the steps) that she needed to accomplish to achieve this. Her goal encompassed a number of dimensions, including cognitive, social, emotional, and physical functioning. Developing objectives and accompanying

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tasks for each of these areas would have been time-consuming and distracting. A strategy that remained helpful was to continue to use self-anchored ratings to assess Esther’s status on relevant traits like depression, anxiety, powerlessness, and fear as these emerged.These challenges are common in most practice settings. Therefore, we must be creative when developing ways of assessing our progress with our clients. At minimum, we can ask clients questions such as how we are doing, how satisfied they are with our work, how helpful our work has been, and the like. There are additional challenges to practice evaluation when we are working with groups, families, and communities. In group work, the same strategies identified in this chapter can be applied to assess each member’s progress. However, this ignores a key aspect of the group modality—namely, that the group as a whole is a client, just as each individual member is. We discuss this point further in chapter eleven. Evaluating outcomes in family practice also presents some unique challenges. There are numerous RAIs that are appropriate for families. Typically, each member is asked to complete the same instrument. However, instruments to measure the family as a whole and its processes and dynamics are lacking. Community and organizational practice often involves numerous individuals taking on a variety of tasks, making the use of task achievement and goal attainment scaling difficult. We will return to these challenges as we discuss these modalities in subsequent chapters.

The Helping Process in

PA R T I I

Life-Modeled Practice

Like life itself, life-modeled practice is phasic. Four phases (preparatory, initial, ongoing, and ending) constitute the processes and operations of the practice. These processes ebb and flow in response to the interplay of personal, interpersonal, and environmental forces. While the phases are presented and discussed to plan their organization, they are not always distinct in actual practice. Chapter 6 examines the professional processes of skillfully entering people’s lives. Beginning a professional relationship requires careful preparation in order to create a supportive environment in which clients can feel comfortable. People must feel safe and accepted before they can trust and confide in a professional. Chapter 7 focuses on the actual beginnings in practice. All helping efforts rest upon shared definitions of concerns, needs, and explicit agreement about hoped-for outcomes, tasks, and reciprocal roles. The ongoing phase is ushered in by the joint recognition that the client and worker have reached a shared, possibly tentative understanding of the nature of the stressors and their desired amelioration. In the ongoing phase, the professional purpose is to help clients effectively cope with the biological, social, emotional, cognitive, and behavioral demands posed by life transitions and traumatic events, as well as to influence the social and physical environments

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so that they become more responsive to clients’ needs. Effective help requires attention to (1) painful life transitions and traumatic life events (chapter 8); (2) associated environmental stressors (chapter 9); and (3) maladaptive interpersonal processes (chapters 10, 11, and 12). We discuss problematic dynamics in groups in chapter 10, in families in chapter 11, and in the worker-client relationship in chapter 12. Social workers must examine and address the interpersonal dynamics that exist in a family and group system and between themselves and their clients when these create or become sources of stress. We believe that considering the three arenas of practice in separate chapters provides readers with greater clarity. We ask readers to remember that actual practice is not as separated as our presentation in this book might imply. Readers will see in the bereavement group presented in chapter 10 that the worker and members had to work simultaneously on the traumatic life event and the interpersonal tensions that erupted in the group, while at the same time constructing a safe social environment that could support the painful grief work. If a social worker is working with an abused woman but not with her partner, the focus will be on the client’s life-transitional concerns (e.g., separation or grief) and/or environmental ones (e.g., linkage to community resources, negotiating with her partner, or securing an order of protection from a court). By contrast, if both partners are seeing the worker, the focus might be on the family’s life transition and or environmental stressors, maladaptive interpersonal communication and relationship patterns, or both. As we discuss in chapter 11, the worker serves as a mediator, helping the couple to communicate more effectively and find alternatives to manage conflict and disagreement. In some cases, the interactions between workers and clients become maladaptive and create stress. In chapter 12, we discuss the skills associated with addressing and resolving them. Ending a professional relationship also requires careful preparation to deal with the feelings aroused by the ending; a review of what has been accomplished and what has yet to be achieved; planning for the future, including transfer to another worker or referral to another agency, where indicated; and evaluation of the service that was provided. Like the initial and ongoing phases of helping, the ending phase requires sensitivity, knowledge, careful planning, and a range of skills on the part of the social worker. We discuss these in detail in chapter 13. As we delve more deeply into life-modeled social work practice, we will be providing readers with many and varied practice examples. These are derived from our practice, as well as those of our students and colleagues. We made a conscious decision to present this material in as honest and straightforward a

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manner as possible. The clients’ challenges and the language they use to describe them may be disturbing to readers. The workers’ actions and reactions to their clients also may be disconcerting. However, what we describe is the reality that students will face in their field practicum, and ultimately in their professional practice. We believe that we do students no favors if we gloss over or avoid how difficult and challenging their work will be. But the examples also reveal how powerful and important our work is, how resilient and courageous our clients are, and how rewarding social work practice is.

Preparation

SIX

Settings, Modalities, Methods, and Skills

Initiating a professional relationship with clients requires careful preparation, ready compassion, and professional skills burnished by creativity.

CREATING AN ACCEPTING, SUPPORTIVE HELPING ENVIRONMENT: CORE SKILLS Anticipatory Empathy

The worker creates an accepting, supportive helping environment by demonstrating empathy—the capacity to get “inside” the client’s life and to experience how the client is feeling and thinking. The use of empathy begins with our earliest encounters with clients, taking into account any information that is available. For example, a hospital social worker, Sarah, receives a referral from a nurse regarding a 60-year-old, unmarried, African American patient, Claudia Anderson, who spent her working life up to then as a school custodian. She had been admitted to the hospital a month earlier for a severe circulatory disorder related to chronic diabetes. This resulted in the amputation of her gangrenous foot and

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leg to the knee. The patient has refused to talk or to follow medical orders and is described by the nurses as “difficult.” Sarah reflects on this information and begins to anticipate—even before meeting Ms. Anderson—what some of the client’s concerns might be. She considers the assault of losing a limb. She thinks about the impact of age and age-specific tasks related to loss of income and financial independence looming ahead for her client. Sarah wonders how the surgery was explained to the client, what social supports she can call on, and what discharge options are available to her. Sarah reflects on the fact that the patient is African American and poor, while the physicians, nurses, and social workers (including Sarah) are white and occupy a more privileged status. She thinks about how Ms. Anderson might view her and her offer of help, based upon the client’s past experiences with helpers (some of whom may not have been helpful). Finally, she considers the environment of the particular hospital ward in which Ms. Anderson was placed, including the staff ’s understanding of their patients’ challenges as a whole. As Sarah engages in this process of anticipatory empathy, she is better able to view the world as Ms. Anderson perceives and experiences it and the meaning that she attributes to her current situation. Anticipatory empathy also sensitizes Sarah to the possibility that Ms. Anderson may have questions about her ability to be helpful given their cultural, racial, and age differences (Sarah is in her thirties). Sarah also considers the medical staff and how they perceive their work, their environment, and their patients, including Ms. Anderson. To be as helpful as possible, Sarah may need to enlist their support as she works with Ms. Anderson. Social workers are always in the process of enhancing their understanding of their clients’ lives and experiences. When we use anticipatory empathy, this requires us to put ourselves in our clients’ shoes, often with only limited information and time. What may at first glance appear to be nothing more than common sense, engaging in anticipatory empathy involves four discrete steps: (1) identification, where the social worker experiences what the client is feeling and thinking in the third person (“she,” in the Anderson case); (2) incorporation, where the worker feels the experiences as if they were personal (“I”); (3) reverberation, where the worker tries to call up personal life experiences that may facilitate understanding those of the client in the first person (“I”); and (4) detachment, where the worker engages in logical, objective analysis (Lide, 1966). Social work students often worry that they will be unable to walk in the shoes of their clients and identify with life circumstances if they themselves have not experienced them. However, we believe that all of us can identify experiences that parallel those of our clients. A childhood memory of parents divorcing can parallel (at least to some degree) a client’s mourning the death of a loved one.

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Always being the last one picked for a sports team in school and consistently rejected by peers provides us with some idea of what it means to be marginalized. Getting a flat tire on the side of a deserted road without a jack or cell phone gives us some insight into the desperation that homeless individuals may feel. When we call upon our own experiences and feelings, we must remember that these are our experiences and our ways of responding to them. Social workers must guard against projecting their own emotions and thoughts onto the client. We must move inside another’s experience as if it were our own, but “without losing the ‘as if ’ quality” (Rogers, 1961, p. 284). This detachment allows us to pull back and reestablish a more objective view of the client’s situation. Let us briefly return to Sarah and Ms. Anderson. Once she receives the referral information, Sarah processes what she has learned as she walks down the hallway to the patient’s room. While her thoughts about Ms. Anderson remain tentative, Sarah considers the following: 1. Ms. Anderson may be confused, overwhelmed, and grieving her amputation. 2. Ms. Anderson may be worried about where she will live and how she will support and take care of herself. 3. Ms. Anderson may question Sarah’s ability to be helpful due to her youth, their racial and socioeconomic differences, and Ms. Anderson’s past experiences with helpers, which may have been unsatisfactory. 4. Ms. Anderson might not fully understand her medical situation. 5. Ms. Anderson may be experiencing difficulties with the medical staff.

With these possibilities in mind, Sarah is more likely to be attuned to Ms. Anderson’s subtle cues, feelings, and reactions to the challenges she faces and to meeting with a social worker. Sarah also is more likely to appreciate that what the medical staff has seen as “difficult behavior” may actually reflect her client’s grief over her lost limb, fears about what the future holds for her, and feeling threatened, embarrassed, and confused by the staff ’s treatment of her. Keeping these possibilities in mind allows Sarah to begin to reflect on how she might approach her client for the first time and be helpful. The following narrative comes from a student, Bridget, assigned to a former client returning to the agency—a community mental health center—for help with several life stressors. The student began by reviewing the case folder: After reading the folder, I had misgivings about working with Mrs. Wilson. Early entries portrayed her as a physical and emotional wreck: cerebral palsy, chronic paranoid schizophrenia, legal blindness, developmental disability, and placement as a

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foster child. I realized I was covering up my fears by being preoccupied with her diagnoses and becoming emotionally detached. Luckily, I caught myself doing this and decided to focus on Mrs. Wilson as a person and not as a label. I found myself experiencing her feelings of being overwhelmed, alone, and scared. I sensed her inner strength and her capacity to endure despite numerous traumas. I pictured her sitting next to me, and I wondered what she would be like and how she would react to me. If I were she, I would be curious about why I was getting a new worker. I might feel that the change of workers was my fault, a reflection of my unworthiness. I might be angry and upset about having to start over with another social worker. At the same time, I might be curious about the worker, maybe hopeful that she could help but also worried that she couldn’t. As I anticipated her possible reactions, several opening statements occurred to me: explaining why I was assigned to her, eliciting her understanding of why the other worker left, listening for her feelings about starting with someone new, sharing what I know about her situation, and inviting her to bring me on board her current situation.

Bridget’s sensitive preparation increased the possibility of engagement and decreased the possibility of being tested by the client, missing nonverbal expressions of anxiety, and failing to understand the client’s unresponsiveness. Like Sarah, this student was at risk of adopting a view of the client based upon others’ descriptions and previous encounters. Medical personnel described Claudia Anderson as “difficult”; Mrs. Wilson’s case file was full of labels and diagnoses, which painted a very grim picture. Once Bridget realized her mistake, she was able to look beyond the labels and begin to see the person they described. Another student described how she prepared to meet with Mr. Sachs, whose wife was terminally ill with cancer: In preparing for the first session, I considered how to introduce likely stressors that might be of concern to Mr. Sachs. I also tried to anticipate his reactions to me and to what I hoped we would discuss. The interview went pretty much like I thought it would. However, afterwards, I realized I stopped short of dealing with his wife’s approaching death. At the time, I was sort of aware what I was doing, but I continued to avoid talking about his wife’s death because it was too painful for me. I prepared for my interview and Mr. Sachs’ possible reactions to his wife’s death, but I hadn’t included my own reactions! I didn’t think about how the loss of a loved one would make me feel. I now see that what I thought was me avoiding causing Mr. Sachs pain was really me avoiding feeling any pain myself.

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Our preparation for understanding clients’ life issues and feelings needs to be flexible, individualized, and multidimensional, and as this last example clearly reveals, it must include how we may feel as we engage with our clients. Workers must be careful that anticipatory preparation does not result in a rigid script or inalterable assumptions about the client. Anticipatory empathy always remains open to additional data and impressions, in order to avoid stereotypes and preconceptions. The student in the previous example had been placed in a hospice program. She quickly learned to adapt her opening comments to the specific needs and situations of her clients. The experience that the student described occurred early in her field placement, and it taught her a very valuable lesson: anticipatory empathy always includes exploring how we may feel. Anticipatory empathy also requires us to consider clients’ cultural, racial, developmental, generational, physical, and social environments and the impact these may have on their lives. This includes issues associated with cultural and social identity, as well as power and privilege. Maria, a 13-year-old middle school student, is referred to the school social worker, Dennis, by the vice principal. She is repeating the sixth grade because of extensive truancy. Truancy officers have visited Maria’s family on multiple occasions. Dennis arranges for a brief meeting with Maria during her free period and plans a more extensive meeting during a home visit with her and her family. Based upon truancy and school reports, Dennis has the following information: • Maria and her 11-year-old brother live with their mother, who suffers from alcoholism and diabetes. They share one bedroom in a small, run-down, three-bedroom house in a dangerous and impoverished neighborhood. The family receives public assistance. • Also living in the household are a cousin, her boyfriend, and their two children, ages 12 and 13. The cousin and her boyfriend are undocumented, but both their children were born in the United States. • Interfamily conflict is continuous. Maria’s parents were divorced when she was 5 years old. Her father remarried and moved with his new family back to Mexico. Maria has no contact with him.

Maria’s records provide Dennis with a rich source of information that he can use, first to prepare for his initial interview with Maria, and then to meet with her family. When Dennis met with Maria, he was especially attuned to their differences and how these might affect her willingness to meet and work with him.

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Dennis is a 30-year-old white social worker. He must consider how Maria, a young, Mexican American teenager, may view him and his ability to be helpful, given her social reality. He also anticipated the possibility that Maria might not see herself as having a problem. She might believe that the problem is the school: if they would just leave her alone, everything would be okay. Workers will have a greater chance of engaging involuntary clients if they address this reluctance directly. When Dennis prepared for the home visit with Maria’s family, his application of life-modeled practice requires him to place Maria’s stressors within the context of her family and the stressors that it faces in the wider environment. He must consider the broader social forces that affect Maria and her family (and might affect their willingness and ability to engage in a working relationship). Salient environmental issues may include the following: 1. 2. 3. 4. 5.

Community violence Poverty, income inequality, and the resulting marginalization Restricted educational, social, and economic opportunities Unsafe and unhealthy physical environment Threat of deportation and anti-immigrant sentiments

Dennis also should give thought to how the family might experience him, as a young white man. He must consider the possibility that the family members might be reluctant to allow him in their home, or even open the door for him, because of the undocumented status of the cousin and her boyfriend. Dennis also must consider how Maria’s family may view him as a helper. We have noted how cultural traditions and perspectives might shape clients’ views of asking for help. These views may either support or undermine clients’ efforts to engage with someone they think is a “stranger” and an “outsider” in a working relationship. Many of our clients will have had previous experience with helpers. If their past experiences were positive, they may approach us with an open mind and a positive outlook. However, they also may expect or want us to be like their previous helpers and have difficulty accepting that no matter how skillful we are, we will be different from previous helpers. If clients’ previous experiences were disappointing and unhelpful, they may assume that their work with us will follow the same path. More generally, clients—even those who willingly seek our help—are likely to approach us with a mixture of ambivalence, fear of the unknown, trepidation, and hope. We realize that large caseloads, laborious documentation requirements, and time constraints associated with contemporary practice may leave social

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workers believing that they have little time to catch their breath and engage in anticipatory empathy. We ask readers to do the best they can—that even a few seconds of preparation is better than none. Anticipatory empathy can be used at any and every moment in the helping process. With practice, as in driving a car, the process of anticipatory empathy—reflecting on clients’ possible reactions, considering how these resonate with our own experiences, identifying our possible reactions, and contemplating how we might be helpful—will become automatic and integrated with our personal style. We end this discussion with one final example drawn from Jane, a 21-yearold white social work student’s experience in a shock trauma center in an innercity hospital. Medical staff were treating a black young man who had been dropped off at the entrance of the center with a gunshot wound to the spine. The young man had ID on him, so medical personnel contacted his mother, with whom he lived. The staff asked Jane to meet with the patient’s mother, who arrived at the center with several family members, all of whom were extremely distraught. Jane’s meeting with the family would occur while the patient was in surgery; the prognosis was unknown, but it appeared to be grim. Jane rushed to the waiting room and had, literally, only a minute to think about what she might encounter when she met the family. She thought that family members would likely be desperate for information about their loved one; overwhelmed by the setting, the medical jargon, and the medical staff; and confused and angry about the circumstances under which their loved one was shot. Jane also considered the environment in which the family and client lived: extremely disadvantaged, crime-ridden, drug-ravaged, and overrun by gangs. Jane acknowledged later that as she ran down the corridor to meet the family, she momentarily experienced feelings of panic and inadequacy. However, she reminded herself that at that moment, the family would not care who she was—they just needed her to understand and respond to their chaotic feelings of confusion and fear. Jane’s recognition, that clients’ sense of urgency may override any concerns they have about their worker and enhance their ability to accept an offer of help, is consistent with the empirical findings, summarized next. Research Findings Regarding Anticipatory Empathy and Engagement

Numerous studies reveal how important preparatory empathy skills are for engaging a client in a helping relationship. When clients are mandated, workers’ ability to immediately acknowledge their reluctance and understand where it comes from is associated with reducing barriers to engagement (Ungar & Ikeda, 2017). This benefit is related to the worker’s willingness to address taboo and

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difficult subjects, including clients’ resentment about being mandated to obtain help and the reason for the mandate, like allegations of child abuse (CohenFilipic & Bentley, 2015; Yoder & Ruch, 2015). Anticipatory empathy also is essential in those settings that provide shortterm help to clients. In hospitals, for example, the medical social worker often meets with the client just once or twice to assist with discharge planning. To accomplish this task, the worker needs to obtain accurate information from the patient quickly, which depends upon the worker’s ability to empathize at the outset of the client meeting (Gibbons & Plath, 2009). This also is true in crisis-oriented settings. Research in these settings indicates that clients’ sense of urgency may override barriers to engagement that might exist otherwise, such as cultural differences (Sweeney et al., 2014). Demonstrating Empathy

Research findings indicate that it is not enough for social workers to understand clients’ social realities; they must be able to convey this understanding. Social workers must be able to communicate their understanding and convey that they are emotionally with their clients. We express interest, curiosity, concern, and caring through numerous nonverbal and verbal behaviors. So the question becomes: how do we let our clients know, right from the beginning, that we are interested, we care, and we are ready to listen? Humans are always communicating verbally and nonverbally, whether they realize it or not. We may remain silent verbally, but the silence itself is a message. The precise meaning of silence can be discerned through the sender’s nonverbal communication. Does the sender roll her eyes and heave a large sigh? If so, perhaps silence means exasperation. Does the sender tap his foot, or rub his hands together? If so, perhaps the silence means anxiety or impatience. Although we may not realize it, we are always trying to create meaning from what others are saying to us. Human communication has been widely studied. Research findings that have relevance for social workers include the following: 1. Humans pay as much, if not more, attention to nonverbal communication than they do to verbal communication when trying to determine the meaning of a message (Knapp, Hall, & Horgan, 2013). 2. If we receive a contradictory message—for example, an individual says one thing to us verbally and something else nonverbally—we will rely upon the nonverbal communication to help us understand what the individual really means (Siegman, 2014).

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3. Verbal, and particularly nonverbal, communication must be understood in cultural and social contexts. Behaviors that are acceptable in some cultures may be unacceptable or misunderstood in others, and the same is true of gender (Burgoon, Guerrero, & Floyd, 2016; Knapp et al., 2013). 4. When humans engage with one another for the first time, they may be reluctant to express their thoughts and feelings directly. Therefore, their nonverbal signals often provide the recipients of communications with a more accurate understanding of what is being communicated (Matsumoto, Frank, & Hwang, 2013).

We now look at these findings in light of nonverbal communication. The Importance of Social Workers’ Nonverbal Communications

As recipients of our communication, clients are going to rely heavily upon our nonverbal messages to assist them in understanding what we are saying to them. Therefore, social workers use posture, gestures, tone of voice, and facial expressions to show attentiveness and interest, and they maintain eye contact as they engage with their clients for the first time. Empathy also is demonstrated by the social worker’s manner of speaking. A soft, gentle tone demonstrates caring, promotes comfort, and may convey sadness about client pain. A more forceful and animated tone can suggest recognition of a client’s strength, while a bland, unanimated tone is likely to convey indifference. Empathic social workers also seek to create a comforting and comfortable environment. When we see clients in an office, we strive to have a physical environment that is inviting. This might include plants, photos, pictures, and comfortable seating arrangements. Many social workers do not have the luxury of having a private, welcoming space in which to see clients. In these instances, nonverbal actions, like smiling when meeting the client and shaking the client’s hand, are especially important (and—if necessary—apologizing for the “tight quarters” and uncomfortable chairs). A comfortable environment also means distractions like ringing phones and staff interruptions are kept to a minimum. The artistry of social work is an important aspect of demonstrating empathy. Our verbal and nonverbal communication must be genuine. Clients will recognize when our verbal and nonverbal behavior is forced or unnatural. Rather than closing the distance between ourselves and our clients and promoting engagement, we increase the distance with insincere communication. Students often worry that if they are genuine, they may say or do something that is “inappropriate,” and therefore harmful to their clients. When we are genuine, but

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we are working under pressure, we will say or do something that would be less helpful than if we had had more time to think through a response. Nevertheless, we believe that genuine and honest communication, in which our words match our actions, is better than communication that is contradictory or insincere. As social workers, we strive for congruence between our verbal and nonverbal communication, and when this is not the case, we clarify what we mean. Further, when we communicate verbally or nonverbally something that is less than helpful, we must acknowledge this, and if necessary, apologize. Melanie was placed in a shelter for homeless adolescents and worked as a case manager, finding her clients permanent housing and other needed services. In class, she described her first meeting with Shavonne, a 15-year-old African American client who had just arrived at the shelter. Melanie was collecting a social history to get an idea of why Shavonne was homeless, and she learned the following: Shavonne reported that her father discovered her in her bedroom having sex with her girlfriend. She said that her father threw the girlfriend out on the street “half undressed.” He then raped Shavonne, telling her that she “needed a big dick, not some disgusting cunt to set her straight.” Shavonne told Melanie that after the rape her father informed her mother that she was some “fucking queer.” Shavonne tried to tell her mother what her father had done, but her mother refused to listen and told her she was “going to hell” and began to beat her. It was at this point that Shavonne left her home, and she does not want to return.

Melanie told her classmates that the first thing that came out of her mouth, because she was so angered by what Shavonne had told her, was: “What assholes!” Was this the most “appropriate” or helpful response? Probably not. Was it genuine? You bet! Could she have found another way to express her outrage on Shavonne’s behalf? Perhaps. However, Melanie’s honest and spontaneous response was better than a response that was canned, rehearsed, or devoid of feeling. In that moment, Melanie revealed her humanness and—without thinking about it—conveyed empathy to Shavonne in a powerful and helpful way. Melanie went on to tell the class that in response to her comment, Shavonne smiled and responded, “They are assholes!” An essential but controversial aspect of social workers’ nonverbal communication is their use of physical touch. Little empirical attention has been devoted to how and under what circumstances (or even if) social workers can engage in physical contact with clients like a hug or pat on the back. The empirical and theoretical literature reflects a contradiction: the importance of touch for

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healthy human growth and development is undeniable, but the use of it with clients generally has been discouraged. The problems with touch include possible misinterpretation by clients, an increased risk of liability, and blurred boundaries. Yet the potential benefits of touch for clients are beginning to be recognized. These include providing clients with validation, support, and a corrective emotional experience (Field, 2010), in which touch is associated with a positive experience rather than a negative one like physical or sexual violence (Novak, 2018; Phelan, 2009). Social workers must be cautious in their use of touch, but we believe that when judiciously offered, it can be a powerful form of empathy and use of self. Based upon research findings and practice wisdom, the following considerations provide guidance to readers in their work with clients (Day & Green 2017; Jones & Glover, 2014): • The worker should ask in advance of initiating physical contact with a client, like a hug or pat. • The worker and client should have a well-established relationship, to minimize misinterpretation by the client. • The worker must examine the reason for physical contact, to ensure that it reflects the client’s needs, not the worker’s. • The worker should consider the cultural and social identities of the client when considering the use of physical contact. • Physical contact should be avoided during discussions of sex and sexuality. • The worker should limit a client’s efforts at initiating physical contact.

The following examples, drawn from our students’ field experiences, illustrate the complexities associated with physical touch: • Sarabeth, age 22, was placed in a residential treatment facility for children. She was working with 8-year-old Emily, who had been removed from her parents because her father had sexually abused her and her mother refused to believe her or leave her father. Sarabeth had weekly play sessions with Emily and questioned whether it was “okay” that Emily always wanted to “touch” and “hug” her. With her field instructor’s help, she understood that Emily might not understand personal boundaries due to the sexual abuse she had endured. In subsequent sessions, Sarabeth limited her physical contact with Emily to a brief hug at the end of their sessions. • Kim, a 25-year-old woman who worked in a continuing care community, met with Elsa, age 87, who just learned that her son had been killed in a motorcycle accident. When Elsa began to cry, Kim hugged her.

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• When saying good-bye to her clients at an outpatient mental health clinic when her field placement ended, Laetitia, a 20-year-old woman, hugged four of her clients—three women and one man in his sixties—and shook hands with two men in their twenties. She had been working with these clients for most of the year of her internship. • Pablo, a 22-year-old gay man, worked in an outpatient health and mental health clinic that served the lesbian, gay, bisexual, transgender, and queer/ questioning (LGBTQ) population. He was meeting with a transgendered client, Taneya, who expressed her grief over the death of her partner. Pablo reached out to hug Taneya, and he later reported to his field instructor that she pulled away and seemed frightened. Pablo described himself as a “compassionate guy,” and he wondered whether he had done something “wrong.” His field instructor helped him see that despite Pablo’s good intentions, Taneya might not have known how to interpret his behavior, particularly since this was their first meeting. Pablo initially questioned this, since he was “gay and no threat” to Taneya. His field instructor helped him see that Taneya had no way to know his sexual orientation and may only have seen him as a man, whom she might see as a threat.

Attending to Clients’ Nonverbal Communication

When we engage with our clients for the first time and over the course of our work, we must attend as much to their nonverbal communication as we do to what they tell us verbally. We must make sure that our clients understand what we are communicating to them. It will often be our clients’ nonverbal behavior that assists us in this regard. Anticipatory empathy can help us make sense of what our clients are saying to us (even when they themselves are not quite sure of this). Empathic social workers note significant shifts and changes in clients’ nonverbal behaviors (such as eye contact, posture, gestures, facial expressions, physical reactions, and changes in vocal quality) that might reflect intense discomfort. For example, when a social work intern probed the recent murder of a client’s husband, she observed the client’s sudden rigid body posture, uncontrolled perspiration, frequent body shifts, and increase in voice volume and pitch. All of these behaviors suggested intense distress. The worker also observes and listens for discrepancies between nonverbal and verbal behavior, and between the manner of speaking and the verbal content.

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Observing a client smiling while her body is rigid, or asserting that she is not upset or angry, but in an agitated tone of voice, suggests that she is unaware of or is trying to avoid acknowledging her emotional reactions. In a first session, the workers demonstrate empathy by pointing out the discrepancy in a supportive verbal and nonverbal way, but they may decide that it is premature to confront and explore the discrepancy in detail, as this might be off-putting to a client. Commenting on these kinds of discrepancies is usually necessary and helpful in later sessions, when the client is more trusting of the worker’s intent. But it also may be necessary when workers have only brief encounters with clients—sometimes only one session. Communication between workers and clients is a complex and critically important aspect of social work practice. So far, we have concentrated on anticipatory empathy and how this is communicated as social workers endeavor to engage their clients in a working relationship. Table 6.1 summarizes the skills associated with conveying understanding at this early point in the working relationship. In subsequent chapters, we will return to empathy and how it is communicated, since this remains an essential skill throughout our work with clients.

Table 6.1 Skills of Anticipatory Empathy and Demonstrating Empathy • Examine available data. • Anticipate possible client feelings and reactions and ways in which these resonate with the worker’s own life. • Reflect on the worker’s possible reactions. • Consider possible actions needed to engage clients. • Respond to clients’ nonverbal cues and behaviors. • Observe and point out, if necessary, discrepancies between clients’ nonverbal and verbal behavior. • Demonstrate interest and concern through responsive body posture, tone of voice, facial expressions, and hand gestures. • Provide a welcoming, comfortable environment for clients. • Provide uninterrupted meeting time, free of distractions, whenever possible. • Speak directly, clearly, and without jargon. • Clarify meaning when the worker’s verbal and nonverbal communication is unclear or contradictory. • Make judicious use of touch and physical contact.

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Anticipatory Empathy and Trauma-Informed Practice

Ongoing research substantiates the disproportionate number of clients with histories of trauma who are seen in settings in which social workers practice and social work students are placed. Throughout this book, we present cases that involve client experiences with trauma in settings, like child welfare, schools, addiction, mental health, and criminal justice/forensics. In any setting where there is the possibility that clients’ present difficulties reflect past trauma exposure, social workers must consider this factor when engaging in anticipatory empathy. Survivors of trauma exposure are likely to experience their social world— including those of us in the helping professions—as unsafe, and to be mistrustful of others and themselves. A sense of powerlessness and loss of control also are common. Trauma-informed practice consists of five interdependent and self-reinforcing elements—trust, safety, empowerment, collaboration, and choice (Berger & Quiros, 2016; Knight, 2019). These principles reflect “the direct opposite conditions of persons who have experienced traumatic events” (Hales, Kusmaul, & Nochaski, 2017, p. 318). The skills that we have described in this chapter are consistent with and will promote these trauma-informed elements. Anticipatory empathy viewed through a trauma-informed lens requires the worker to attend to four considerations. First, social workers consider the possibility—but do not presume—that the current problems that brought clients to them voluntarily or involuntarily reflect exposure to past trauma. Second, the worker anticipates that clients’ reluctance to engage may reflect generalized feelings of mistrust resulting from past trauma. Third, in the initial encounter, clients may not volunteer their trauma history because: they do not see the connection between the past and the present; are embarrassed by or reluctant to discuss past trauma due to its associated pain; or they are unable to sufficiently recall the trauma. A common way that trauma survivors—particularly those exposed in childhood—manage the experience is through repression and memory loss (Hales et al., 2017; Rossiter et al., 2015). Fourth, we must use our empathy skills to engage clients who potentially are trauma survivors in a way that creates safety and trust, promotes honest discussion, and is empowering. These characteristics are essential to establishing working relationships with all clients. But they are critical when social workers engage clients who may be trauma survivors.

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CREATING AN ACCEPTING AND SUPPORTIVE HELPING ENVIRONMENT: WORKING WITH FAMILIES AND GROUPS Working with Families

When we are meeting more than one member of a family—as was the case with the school social worker, Dennis—the same skills associated with anticipating client concerns and conveying empathy remain relevant and necessary. One aspect of family work that distinguishes it from other modalities is the need to consider whom to include in a first meeting. Social workers often find that an initial meeting with all members of a family provides them with valuable information as they observe family members’ interactions with one another. In other instances, the worker may begin with a subset of family members for practical reasons (a very young child may be disruptive in the session; a school may require the social worker to meet with the child and a parent or parents). Decisions regarding the composition of a family meeting also may reflect the worker’s assessment of who should be included (or excluded) to address the difficulties that required the family—and/or an individual member—to seek assistance. Another significant difference is that instead of thinking about the reactions, thoughts, and experiences of one client and attending to a single client’s verbal and nonverbal behavior, the worker must consider each family member’s perspective and verbal and nonverbal behaviors. A further distinction is that we must attend to family members’ behavior toward us as well as toward one another. For these reasons, the skills we have discussed and summarized in table 6.1 may be more challenging because of the increased amount of information that we must process. In chapter 10, we discuss in more detail patterns of communication in and ways of working with families. We want to briefly return to Dennis’s planned visit with Maria’s family to highlight the unique aspects of anticipatory empathy in a family context. Previously, we discussed the importance of Dennis considering the family’s mezzo and macro environments and how these may affect the family, as well as their ability to engage with him. He also must consider intrafamilial dynamics that reflect roles, norms and expectations, and communication patterns and family members’ unique way of interacting with one another, as well as how each member might experience him. In other words, he must think about

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the family as a whole, as well as each individual member. Possibilities include the following: 1. Maria’s mother and brother may resent or at least experience some ambivalence about the presence of her cousin and her cousin’s family. 2. All members may resent and/or be stressed by a lack of privacy in their household. 3. Members may experience confusion about who is in charge. Maria’s mother may technically be the parent in the household, but she is disabled by diabetes and alcoholism.

When Dennis first meets the family, he will need to consider these possibilities, in addition to those that we previously identified, and understand that it is likely they will first reveal themselves nonverbally, underscoring yet again the importance of attending to clients’ nonverbal communication. This includes where members position themselves in the meeting. For example, let us assume that when Dennis first meets the family and everyone takes a seat, the members arrange themselves as follows: • The mother sits in a chair off in a corner. • All four children (Maria, her brother, and her cousin’s two children) sit close together on a sofa. • The cousin and her boyfriend sit on two chairs positioned close to one another and to the four children. • All members but the mother engage in casual conversation with one another.

Further, as Dennis introduces himself to the family and asks for members’ input, he observes the following: • When the mother speaks, Maria and her brother laugh, roll their eyes, and whisper to each other. • When asked a question, the cousin’s two children are silent and look to their parents. • When the cousin speaks, her boyfriend interrupts and takes over the conversation.

Dennis could use these observations to further inform his ability to empathize. For example, the mother’s alcoholism and medical problems may place her in a weakened position within the family. Maria and her brother may have more power in the family than is appropriate, given their age. Meanwhile, the boyfriend may have a dominating influence over his girlfriend and their children. While Dennis does not know for sure whether any of these possibilities are

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applicable to this family, taking them into consideration enhances his ability to empathize and quickly enter their world. Forming a Group

Developing anticipatory empathy and demonstrating empathy are essential to social work practice with groups. Consistent with how social workers prepare for work with a family, they will need to attend to the verbal and nonverbal behavior of each member of the group, as well as the group as a whole. There are, however, tasks and skills of forming a group that are distinctive to this modality. Mutual Aid

To understand the benefits of group work and its associated tasks and skills, we must understand the concept of mutual aid (Lee and Swenson, 2005). The source of help in group work lies with the members themselves. Members’ interactions—which are fostered and encouraged by the social worker—provide them with support, validation, understanding, learning, and encouragement. From its inception in the settlement house movement, group work has emphasized and promoted empowerment through members helping one another (Gitterman, 2017). The emphasis on members helping one another is associated with five interdependent benefits that distinguish group work from other modalities. Once members discover that they are not alone—a phenomenon known as all-in-the-same-boat (Shulman, 2012, 2017) or universality (Yalom & Leszcz, 2008)—they are enabled to work on the challenges they face. “Group members walk in the same shoes and, therefore, have a keener understanding of each other’s life stressors, challenges, and distress. Their provision of support and demand for work has a unique impact, given the credibility that comes from being in the ‘same boat’ ” (Knight & Gitterman, 2014, p. 7). As members provide support to others in the group, their sense of selfefficacy is enhanced, which in turn promotes resilience (Knight, 2017b). Members also derive benefits from being able to help others rather than being solely the recipients of help. Yalom and Leszcz (2008) refer to this as altruism. Members may learn from the group worker, but they often learn their most valuable lessons from one another, which leads to greater self-understanding and a more realistic perception of themselves and the challenges they face (Anderson & Lopez-Baez, 2011). The sense of connected to others that comes from being in the same boat leads to cohesiveness and a sense of “we-ness.” This, in turn, enhances self-esteem and self-worth (Huang & Wong, 2013).

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Research findings derived from a wide range of settings and client populations of all ages and social and cultural identities underscore the unique benefits of group membership. A representative sample of recent findings reveals that group participation: • Reduces defensiveness and enhances motivation and commitment to change among batterers and individuals with substance use disorders (Wendt & Gone, 2017) • Improves compliance with medication directives and symptom management and reduces feelings of self-stigma for clients with significant mood disorders (Kunikata, Yoshinaga, & Nakajima, 2016; Ramaprasad & Kalyanasundaram, 2015) • Promotes healing among bereaved individuals (Linde, Treml, Steinig, Nagl, & Kersting, 2017) • Promotes resilience among children and adolescents who have experienced various form of trauma (Sinha & Rosenberg, 2013) • Reduces social isolation and depression among aged adults (Duyan, Sahin-Kara, Duyan, Özdemir, & Megahead, 2017)

In social work practice with groups, we always have two clients: the group as a whole and each individual member. Mutual aid cannot be achieved effectively unless we attend to how members are interacting with one another. Members’ relationships with one another must promote and support members’ work. This requires that the worker constantly monitor members’ individual and collective behaviors and, when needed, intervene to modify those that may undermine the group’s work. Group Purpose

In preparing to form a group, the worker must develop certain specialized skills, such as clarity about the group’s purpose. A group evolves from a common need, around which prospective members are brought together. This commonality is essential to the development of mutual aid. Mutual aid can develop only in a group where members need each other to deal with common stressors, concerns, and interests. The life model’s three interrelated stressors (life transitions and traumatic events, environmental pressures, and interpersonal processes) can be used to conceptualize the rationale for and purpose of the group. Groups can assist people with successfully mastering life transitions across the life course. Examples include adolescents dealing with their sexuality, “aging out” of foster care and needing assistance with becoming independent, or both;

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and parents adopting a child from a foreign country. Physical, cognitive, and emotional impairments can undermine the accomplishment of developmental tasks. Therefore, a group experience can be designed for learning, emotionally, developmentally, and/or physically disabled adolescents or adults to help members deal with their common and distinctive life struggles, such as developing appropriate social skills or learning how to engage in self-care and activities of daily living. Groups can be formed to help with life transitions that may be even more stressful. Examples include groups for newly divorced individuals, the children of divorcing parents, bereaved individuals, newly arrived immigrants, and women who have had mastectomies. In other cases, a group can help individuals who face a transition that challenges where they are in their phase of life, such as pregnant or parenting young adolescents or grandparents raising their grandchildren. Groups also are created to support and empower people who occupy stigmatized or marginalized social identities, including LGBTQ individuals, individuals with substance abuse stressors, individuals living with HIV/AIDS or mental illness, sex workers, and people identified as “homeless”. In some groups, such as those for people dealing with substance abuse disorders, members are helped to deal with the stressors that may have contributed to the devalued status in the first place, as well as the consequences of their issues. Exposure to a traumatic event or events represents an especially challenging life transition. The stress that is created is often more intense and overwhelming because the event or events are outside the normal human experience. Individuals who benefit from group membership under these circumstances include rape victims, survivors of a natural or human-made disaster, adult and child victims of sexual molestation, and loved ones of a victim of homicide. Group services also can be offered to the significant others of these individuals to help them cope with the associated stress and with supporting and caring for their loved ones. Social and physical environments are a major source of stress and groups can be formed with an environmental focus. A group may be formed to help with life transition issues, but it also may focus on environmental stressors that negatively affect members. A group formed for any purpose may need to deal with internal organizational obstacles, like agency structure (for example, lack of evening hours) or the quality of services (such as institutional food). Groups also may be explicitly formed to deal with environmental conditions that create stress for clients. They may provide members with the opportunity to influence an agency’s planning and decision-making structures. A planning

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committee, an advisory group, or a leadership council can enhance an organization’s responsiveness to clients and also empower participants. Social workers also organize groups with a social action focus to empower clients to deal with social injustice. These include groups formed to address police brutality, unresponsive government services, and lack of affordable housing. Unfortunately, many agencies, and even social workers themselves, do not recognize that the benefits of group participation extend beyond helping members manage life transitions. For many of our clients, the social environment is the source of their stress. At the very least, it can undermine clients’ adaptive capacities. Group participation also can benefit naturally occurring social groups. Patients in psychiatric wards, students in classrooms, and roommates in residential cottages often experience relational and communication problems. These social groups can develop interpersonal stress due to maladaptive communication and relationship patterns that result in discontent, conflict, and disagreement. For example, in a residential cottage for adolescents removed from their homes for behavioral or emotional problems, the teens may experience difficulties with living together 24 hours a day. The stress associated with the life transition of moving to a residential facility is both manifested in and reinforced by the stress that develops among the teens. A social worker can work with this type of natural social group, helping members modify maladaptive interactions and facilitate communication. Beyond intervening in natural social groupings, workers form groups with an explicit interpersonal focus. Couples and multifamily groups, for example, provide a natural modality to examine and work on relational and communication patterns. Group Type

After identifying the group’s purpose, which will then guide the recruitment of potential members, the social worker considers the type of group that will benefit the members. Groups can be designed to (1) be educational, (2) deal with common stressors, (3) encourage behavioral change, (4) encourage social development, (5) engage in task accomplishment, and (6) promote social change. In a group with an educational focus, participants acquire relevant knowledge and information, such as coping with a child suffering form schizophrenia, dealing with diabetes, practicing safer sex, and preparing for surgery. In these groups, the worker finds a balance between presenting information and encouraging discussions in which members have an opportunity to process and help each other understand and use the information. Predetermined “curricula” are

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readily available to guide social workers in educational groups for anger management, stress reduction, managing mental illness, and the like. However, if the worker adheres too rigidly to the manual, the mutual aid potential of the group will be lost. In a group with a common stressor–solving focus, members help each other with common life transitions and environmental or interpersonal concerns, such as raising a developmentally challenged child, coping with divorce, dealing with the death of a loved one, or confronting spousal abuse. In these groups, workers help members develop a system of mutual aid whereby members support and learn from them and from one another. In a group with a focus on behavioral change, members are helped to achieve such goals as to parent more effectively, develop techniques to manage anger or stress, lose weight, and attain sobriety. The group serves as a context and impetus for individual behavior change. Groups with a social development focus help members learn the interactive skills of making friends and building emotional and social connections. This might include a social skills group for individuals with mental illness and a music group for isolated aged individuals in a nursing home. The worker often uses activities to encourage members to engage with one another. Task-focused groups center on members completing prescribed objectives and achieving a common goal. These groups include planning and advisory committees, team and staff meetings, ad hoc task forces, and the like. In these groups, there may not be a designated leader, but when social workers are in this position; they help members work together collectively to resolve the assigned task. Groups with a social action emphasis are a variation on task-focused groups. They provide members with the opportunity to work together to effect change in their social environment. This is based upon the assumption that there is power in numbers. Members will have more of an impact on unresponsive systems if they work together rather than taking a task on individually. Implications of Group Type

Identifying one specific group type often is difficult. For instance, an anger management group may have an educational focus and teach coping techniques, but it also is designed to effect behavioral change. A group for survivors of intimate partner violence may provide information about the cycle of violence, help members help each other to manage the stress of being a victim, and lead to changes in behavior like developing a safety plan or leaving the abuser. A group with an educational focus may take on elements of stress management. For example, a student was facilitating an anger management group

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for elementary school–age boys. The members’ conversations with one another and with her revealed that they were dealing with a number of difficult family situations, including a parent’s incarceration, a sibling’s drug addiction, and the loss of the family home due to foreclosure. The social work student recognized that members’ anger issues in school were associated with the stressors with which they were dealing. Therefore, she modified her group and her role to encourage members to share their struggles with and support one another, as well to present techniques they could use to control their angry outbursts in the classroom. A group designed to help members cope with stressors may become engaged in social action. Another social work student was facilitating a group for seniors in a day program that focused on decreasing social isolation through music and movement. Members often complained about the lunch that they were served, which they described as boring and lacking in variety. The student asked the members whether they would like his help in approaching administrative staff at the agency to discuss making changes in the lunch menu. As members worked together to develop an approach strategy, this furthered the initial goal of reducing isolation, and it had the added advantage of empowering members and addressing a significant stressor in their environment. The social worker strives to select the type of group that best fits the prospective members’ needs and the resulting group purpose. This will require that the worker remain flexible and open to renegotiating with members how they will go about accomplishing their work. For example, a student worker formed a task group for parents of developmentally challenged children to create community resources for their children. Although potential members agreed to participate in the group, they appeared uninterested in the work and did not follow through on agreed-upon tasks. The student worker shared her observations with the members and learned that they wanted and needed to share their frustrations about the lack of social support and to help one another with child-rearing. The student had proposed a task group, but what she and the members discovered they needed was a group that would assist them with the life stressors associated with parenting a developmentally challenged child. The process of renegotiation may include acquiring agency sanction and support for the proposed changes in the group’s purpose and type. The social worker pays attention to both group member needs and agency expectations. The worker’s consistent focus is on finding and nurturing the common ground between the agency’s mission, structure, and goals and the group members’ needs.

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Group Composition

Group composition is yet another specialized group formation task in the preparatory phase. Research indicates that groups composed of members with common background characteristics, like age, gender, race, ethnicity, and social class, and similar personality traits and behaviors, like interpersonal style and degree of extraversion or introversion, tend to quickly develop a group identity and a sense of cohesiveness (Burlingame, McClendon, Theobald, & Alonso, 2011). Similar backgrounds provide members with a sense of “we-ness” that complements their mutual need and promotes comfort. However, when members are too alike—when the group is overly homogeneous—this may undermine the group’s ability to achieve its purpose. Excessively homogeneous groups can limit the diversity and vitality that are essential to challenge the status quo, to create the necessary tension for change, and to provide models for alternative attitudes and behaviors. For example, a group comprised solely of depressed individuals might fail to achieve its purpose of helping members better manage their life stressors, and triggers and consequence of their mood disorder such as the side effects of their medications because they have limited ability to interact with one another. A group comprised of members with a substance abuse disorder, or of men who have abused their partners and who have not taken responsibility for their actions, might reinforce minimization and denial. In contrast, groups that are heterogeneous—that is, composed of members with diverse background characteristics and diverse personality traits and behaviors—may struggle to develop cohesion and a shared sense of identity. Differing backgrounds may create obstacles that prevent members from connecting with one another. Members may experience one another as too different, and this perception may obscure their common need and undermine the group’s purpose (Burlingame et al., 2011). For example, a group was formed for racially diverse youngsters with school difficulties. Rather than recognizing their shared issues about school, the members focused on their differences, which led to subgrouping and scapegoating. These internal barriers impeded members from working on their shared purpose, which was to deal with stressors that interfered with school success. In many groups, the worker will have to help members recognize their underlying commonality of need and shared purpose because there is likely to be both elements of heterogeneity and homogeneity. At a minimum, prospective members need to have common concerns and interests—a commonality of

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purpose. Once the common purpose has been identified, the social worker considers the desired range of commonality or difference in important background and personality factors. In developing a group for pregnant adolescents, for example, the social worker must consider the relative advantages of commonality or difference for factors such as first pregnancy, stage of pregnancy, plans for the baby, religion, ethnicity, parental and boyfriend relationships, health, geographic location, and others. Generally, members tolerate greater diversity when common interests and concerns are experienced intensely. For example, one of the coauthors formed a group for women with limited life expectancy due to advanced breast cancer. The group members were quite diverse in their backgrounds. They ranged in age from the mid-twenties to the mid-seventies and came from different socioeconomic backgrounds, religious affiliations, racial and ethnic groups, and phases of life. However, their profound commonality of a terminal diagnosis of breast cancer made the differences seem inconsequential. In contrast, in the racially diverse school group mentioned previously, the members’ need for assistance from one another was much less intensely felt. In this case, the worker needed to pay closer attention to and emphasize members’ underlying commonalities to assist them in looking beyond their differences. Even when members share the underlying commonality reflected in the group’s purpose, ambiguity regarding heterogeneity and homogeneity often remains. Potential members may struggle with the same stressor or life transition, but their individual experiences are nonetheless specific to them. Therefore, the worker must determine whether the “same-ness” of the experience will override its “different-ness.” The following example illustrates how challenging decisions in this regard can be. Tanya was placed in an outpatient psychiatric program located in an urban, impoverished neighborhood. Many of the clients sought help from her agency to deal with grief following the death of a loved one. She decided to create a grief group (a stressor-focused group) that would allow members to share their grief with and garner strength, support, and assistance from one another. Potential members would be adults who had lost a loved one. Tanya’s recruitment efforts resulted in the following potential members: • Three mothers and one father in their thirties and forties who had lost their sons to gun violence • A 40-year-old woman, Mavis, whose husband died of cancer • A 22-year-old man whose twin brother died after being knifed in a robbery • A 30-year-old woman whose younger sister was a victim of domestic violence • A 50-year-old man whose wife had been raped and murdered

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All of these potential group members were African American /Black. Tanya and her field instructor agreed that members’ background characteristics associated with age, race, and gender were unlikely to present challenges to developing mutual aid. They did question whether the group that was forming would be a good fit for Mavis, the woman whose husband died of cancer. While she did share the underlying commonality of loss of a loved one, her loss was quite different from that of the other potential members of the group. There also were differences in experience among the remaining seven potential members, but the clear commonality was that their loss was due to the criminal behavior of others. The question that Tanya and her field instructor struggled with was, “Would Mavis’s shared experience of loss be enough to override the differences in the context of her loss?” The answer to Tanya and her field instructor’s question can be guided by the Noah’s Ark principle (Yalom & Leszcz, 2008), which holds that whenever possible, each member of a group should share with at least one other member characteristics considered central to the group’s work. A parallel principle is “not the only one” (Gitterman, 2005), which suggests that no one should stand out as the sole member with a characteristic that is relevant to the group’s work. In both cases, salient characteristics would include those we already have identified: background, behavioral, and those associated with a member’s need for the group. Even with this guidance, decisions regarding the level of fit of a potential member may not be clear-cut. In Tanya’s case, she and her field instructor could answer their question either way. In a perfect world in which resources are plentiful, Tanya’s agency could offer two groups, one for those dealing with a loved one’s death from violence and one for those dealing with a more “expected” (but nonetheless painful) loss. Tanya and her field instructor ultimately decided that Mavis herself should make the decision based upon the advantages (being with others in the same situation) and potential challenges (experiencing a loss that was different in a significant way). Mavis decided she would attend the group since there were no other options. Once the group commenced, Tanya understood that she would need to make sure that Mavis felt connected to the group (and vice versa). We discuss the skills needed to do this in chapter 11. For another example, consideration of the two composition principles led to a different outcome. Derrick was placed in a youth diversion program. Adolescents who are first-time offenders found guilty of less serious adult offenses are given the opportunity to attend his program in lieu of incarceration. The agency has noted the large number of youths who are the victims of childhood sexual abuse, and Derrick’s field instructor has asked him to create a group for these

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adolescents. The group that Derrick and his field instructor envisioned would be a combination of what we have referred to as education, stressor-focused, and behavioral change. The purpose would be to help members understand sexual abuse and its connection to their current life transitional and environmental stressors, normalize and validate their feelings and reactions, and identify ways of coping that did not involve criminal behavior. Derrick received referrals for seven potential members. Five adolescents appeared to be good fits for the group, but Derrick questioned the appropriateness of the other two. All seven potential members were between the ages of 15 and 17 years old. Four were African American, two were Puerto Rican, and one was white. All seven had been convicted of similar crimes involving assault, and a father or other male caregiver had abused all seven in similar ways. Six potential members were young men, but one was a young woman. After much deliberation, Derrick and his field instructor decided that the members’ shared sense of urgency would most likely minimize the likelihood that the sole white teenage boy would feel like “the only one.” Derrick did recognize that he would need to attend to signs that this young man might be—or feel—singled out because of his race. In contrast, even though the one young African American woman also shared critical characteristics with the other members, Derrick and his field instructor believed that her experience of abuse—as a young girl—might be different enough to prevent her from fully connecting with the other members. In some situations, such as Tanya’s, the worker may consider letting the potential member decide about level of fit; in others, however, the worker needs to make this decision. Group Structure: Temporal Arrangement, Group Size, and Physical Setting

Group purpose, type of group, and organizational context all influence the group’s temporal arrangement. Most groups are planned and short-term. Time limits help members focus quickly and maintain a purpose, direction, and sense of urgency, and have been found to enhance motivation and commitment to work (Lau et al., 2010). For certain populations, a short-term group is imperative. The previously mentioned group of cancer patients with a limited life expectancy would have been devastated by the death of a fellow member, even if new members were added. A 1-session orientation group that prepares hospital patients for surgery, a 2-session postsurgical group, a 4-session adoptive parents group, an 8-session couples group, or a 12-session group of foster care adolescents each may offer helpful as well as practical ways of meeting members’ needs.

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In some situations, as the group nears completion and evaluates its progress, the members and worker may decide to recontract for another cycle, or for a specific number of additional sessions. When the coauthor led a group for women going through a divorce, the members decided at the last meeting to have two additional meetings, a month apart. In time-limited group services, the worker clearly identifies the ending date in the first session. Certain settings, such as schools, have a natural time frame based upon the academic year that groups are likely to follow. Religious holidays, winter/spring breaks, and end of the school year provide natural time frames to end the group or benchmarks to evaluate progress and determine if additional time is needed. Time limits may be somewhat arbitrary, but they may be necessary due to agency policies, structure, or both. In other cases, time limits will reflect the realities of clients’ lives and the need to enhance their commitment to attending the group. Whenever possible, time limits should reflect the worker’s assessment that the number of sessions is sufficient to achieve the group’s purpose. The following are examples of time-limited groups that our students have led: • The student is placed in a neonatal intensive care unit (NICU) of a major urban hospital. Many of the babies have been born to very young teenage mothers, who appear ill at ease and uncomfortable with their babies and as a result are reluctant to engage with them. Once a week, she hosts a “doughnut and coffee klatch” for any of the teen mothers who are still patients themselves, or who are visiting their babies. Because of the nature of the setting, most members attend only once or twice. • The student is placed in an outpatient drug treatment program. He is going to be leading a group for aged clients who suffer from a substance disorder. The agency had long believed that the needs of these individuals had not been adequately met by other group offerings that tended to include much younger clients. The student decided to offer a 10-session group, which reflected his clients’ restricted ability to travel to the agency due to limited transportation options and disability challenges.

Long-term groups are more likely to be open-ended and ongoing. In these instances, new members replace departing members. This type of group best serves clients with chronic and intractable personal and environmental stressors (Miller & Mason, 2012). For example, chronically mentally and developmentally challenged clients, as well as their caregivers, may benefit from the continuous support provided by long-term groups. These group members need much more help than short-term services can provide. Open-ended groups, however,

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do have two common problems: (1) the ongoing, long-term nature may lead worker and members to lose their original sense of purpose and vitality; and (2) the shifts in membership that comes with members joining and leaving results in the group’s inability to move beyond an early phase of group development (Turner, 2011). To minimize disruptive membership shifts, the worker attempts to manage group members’ entrances and exits. If only one new member joins a group, the group usually is able to incorporate the new member into its current phase of development. In contrast, frequent arrivals and departures of members require the group to slow its processes and return to beginning group issues. The worker needs to process with departing, new, and ongoing group members the departure of old and addition of new members. Group members need to be involved in the change process rather than experience it as arbitrary and out of their control. Other time considerations are the frequency and duration of sessions, which should be structured and arranged in ways that are responsive to the unique needs of the population being served. For example, in providing group services to young children in schools, the coauthor discovered weekly sessions for an hour were both insufficient and too long. During the interval between sessions, the youngsters confronted various school and family crises, and the group was unavailable for assistance. Consequently, the worker restructured meetings for greater frequency (twice or three times weekly) and for shorter duration (30 or 40 minutes), which better reflected the members’ ability to stay focused. This time change made dramatic impact upon both the substance and intensity of our work. Generally, children and mentally, emotionally, or cognitively challenged adults are responsive to more frequent and shorter sessions, while well-functioning adolescents and adults are responsive to longer sessions (one-and-ahalf to two hours), held weekly. In some settings, like medical or aged services, stamina, physical discomfort, and pain may make shorter sessions necessary. Essentially, the worker must creatively structure time by taking into account group members’ developmental phases and special population attributes and their effect on attention span and capacity for session-to-session carryover (Burlingame et al., 2011). The worker also must consider the potential consequences of the scheduled time for the meetings. Some members may be able to attend meetings only in the daytime because their children are in school or because of safety concerns. Others, due to employment and other reasons, may only be able to attend evening hours. To the extent possible, involving potential group members in

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identifying the most and least preferable times for scheduling group meetings increases the likelihood of their participation. Appropriate group size is related to group purpose and type. Generally, larger groups (approaching 20 or more members) will need to become more formalized. Communication may have to be channeled through the designated leader, with limited opportunity for individual attention, accessibility to the worker, and intimate, spontaneous participation. Since community groups are designed for social action and depend upon “power in numbers,” large numbers of members are preferable. As we discuss in chapter 11, this will require the worker to help the group develop a structure for its work. For most of the groups that social workers are likely to lead, group size typically ranges from as many as 12–15 members to as a few as 4–5. Groups that exceed or fail to meet these size ranges may achieve their purpose, but workers must consider the challenges that they may encounter. For some clients, such as those with chronic mental illness, young children, or the frail elderly, large groups may be overstimulating and confusing, leading to members’ withdrawal and isolation. Clients who are shy, withdrawn, or socially isolated might find a larger group intimidating, which may undermine their ability to benefit from participation. Smaller groups offer greater opportunity for individualization, providing each member with sufficient time and accessibility to peers and the worker. Members in crisis, for example, often need the attention afforded by small groups that meet frequently. Similarly, emotionally neglected or abused children need the continued and special attention that they are more likely to get in a small group. Small groups, however, make greater demands for participation, involvement, and intimacy. While shy, anxious, or more socially awkward members may benefit more from such groups, they may need the worker’s help to do so. A moderately sized group (approximately 6–8 members) is likely to be beneficial to most client populations, as it balances opportunities for intimacy with opportunities for distancing. Groups with three members might still be beneficial (for example, for hyperactive kindergartners or developmentally challenged adults working on social skills), but they may be unable to provide mutual aid. If one or more members miss a session, the group becomes a dyad or triad. Further, such a small group may lack the vitality that results from a diversity of members. The size also should reflect the group’s purpose and type. Generally, groups with an educational focus can be larger, while groups focused on stressors are more helpful when they are smaller (Bernard et al., 2008). Depending upon its specific focus, a task group will typically fall in the moderate size range. Groups

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with an emphasis on behavioral change and social development also are likely to fall into this range. Finally, the physical setting also has a significant impact on a group’s activities and interactions. Light, ventilation, room size, and furniture arrangement facilitate or inhibit the development of mutual aid. In arranging the space, the worker assesses members’ comfort and communication style. A circular seating arrangement facilitates member-to-member communication and is usually preferred. However, in certain situations, the circular arrangement may create selfconsciousness and unease. A small circle also can be threatening to members who do not seek or are not ready for the degree of physical and emotional intimacy that such a structure demands. In these situations, tables may provide the necessary spatial boundary and distance that members require. Tables also may be necessary if the group (for example, one that is focused on children) uses activities. If the members need physical movement, however, tables are restrictive. Since predicting members’ spatial needs is difficult, the worker should have options available to change seating arrangements if or when they are needed. Group Leadership

There has been much debate and discussion about the relative benefits of single leadership versus coleadership. Research evidence suggests that neither model is more effective than the other. Toseland and Rivas (2017) identify the salient benefits of coleadership, which include the following: • Leaders can provide support to one another. • There is the opportunity for feedback and skill development, particularly for inexperienced group workers. • The leaders will have an enhanced ability to attend and respond to members’ interactions with one another. • Leaders may serve as role models of open and healthy communication and dealing with differences and disagreements.

In some settings, coleadership can allow members to benefit from the expertise of two different disciplines. For example, a nurse or doctor with medical expertise and a social worker with the skills needed to promote mutual aid can jointly provide a more comprehensive experience to members of a group for patients who are recipients of a new heart.

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However, coleadership often reflects workers’ discomfort and anxiety about working with groups. We have had many students tell us that they were afraid of working with groups because “there are so many of them and only one of me.” As students come to understand that the benefits of group work lie with the members themselves, and not solely with the worker, this lessens their anxiety. Despite the benefits of the approach, evidence suggests that coleadership also can undermine the group’s purpose if the coleaders have differing perspectives regarding their roles, the purpose of the group, and the ways of working within the group (Toseland & Rivas, 2017). Coleaders must be able to reach an explicit agreement on their respective roles and the tasks, particularly in the beginning, ending, and focusing sessions. Coleadership does not mean that each leader assumes equal responsibility and gets equal time in each session. The leaders must clearly understand and agree about their respective roles and responsibilities. The agreement between leaders should be communicated verbally to members, but it probably will be apparent even nonverbally. Members will be quick to sense when there is discord or disagreement, or when the leaders are not on the same page. For example, while a medical professional and social worker might offer patients who have received a new heart more comprehensive assistance in managing this significant life transition, the benefit would be undermined if the medical professional did not understand mutual aid and its centrality to group work and the leaders’ role in fostering it. While students and inexperienced group workers may be threatened by the prospect of facilitating a group on their own, sole leadership of groups emerges as the most straightforward approach. Coleadership requires a greater expenditure of scarce resources, including the need for leaders to make time to process their and group members’ interactions after each session. Coleadership also adds more complexity to the group dynamics—namely, the leaders’ struggles to synchronize their interventions and to cope with role ambiguities, competitiveness, and discrepant interventions (Toseland & Rivas, 2017). Unwittingly, this arrangement may inhibit the group’s mutual aid processes by encouraging withdrawal, testing, or identification with one leader at the expense of the other. Creating a Responsive Organizational Climate

Organizational support is essential to the development of group work services. Without administrative approval, the worker is “walking on eggshells.” In response to any perceived problem, such as uncooperative patients in a hospital or noisy children in a school or social agency, the medical or psychiatric chief, school

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principal, or agency director may precipitously terminate the group. Similarly, without administrative and staff support, a group offering is easily undermined or sabotaged—coworkers do not refer appropriate clients, nurses suddenly have to take patients’ temperatures, or teachers decide to punish children for class behavior by disallowing group participation. Structural supports are also essential to the development of group work services. A worker’s office may be too small, while an auditorium may be too large. If a group is to meet its mutual aid potential, the agency must support the worker’s choice of a suitable location. When necessary supports like space requirements are not negotiated beforehand, the result is administrative, worker, and group member frustration. Chapter 15 discusses the methods and skills connected with acquiring institutional sanctions and supports. Managing Agency Constraints on Group Work Practice

What we have discussed so far reflects what may be best viewed as best practices when preparing to start a group. The context of the many settings in which social workers practice, as well as the realities of clients’ lives, may prevent the social worker from making some (or even possibly many) of the necessary decisions that we have just outlined. Ideally, workers move through each of the tasks; they identify a need for a group and take the steps necessary to make the group happen. The group is created to fit client need. In practice, the reverse is often the case; the worker fits the client into a new or preexisting group based upon agency structure and priorities. In these instances, social workers should strive to adhere as closely as possible to the guidelines that we have presented. However, they will need to make adaptations to accommodate agency realities and be sensitive to challenging dynamics that may result. The following examples are drawn from our students’ group work experiences in their field practicum: • Tammy was placed in a shelter for homeless families. She was tasked with running a group one day a week that was mandatory for any adult resident who was in the shelter at the time the group met. Residents were typically women, though there were some single fathers and some two-parent families. Most had experienced numerous traumas, including childhood abuse and domestic violence, in addition to being homeless. Many also had a substance abuse disorder. Tammy wanted to lead a group focused on dealing with the traumas in the residents’ lives. However, the realities of her setting precluded this. The turnover in membership was high,

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and the number of members varied every week, though it averaged 12–15. These factors inhibited the development of the cohesion necessary for the group’s members to talk openly about the pain and distress associated with their traumatic experiences. Therefore, the group that Tammy actually led had an ever-changing purpose that reflected the members’ sense of urgency in any given week. • Manuel was placed in a day program for homeless men. The shelter was open to adult homeless men and provided clients with a place to shower, read, watch television, and receive case management services, breakfast, and lunch. Some men came regularly, but most came in on an irregular basis. Manuel was tasked with starting a group but had no idea where to start. He wanted to lead a group that helped the men find permanent housing, as well as addressing the many challenges they were experiencing in their lives (like addiction, incarceration, mental illness, and abuse as a child). He envisioned a group that would provide stressor relief, education, and behavior change. However, the group that he actually led was a current events group that provided any client who was interested in attending the chance to connect others, share their opinions and ideas, and learn about what was going on around them. • Sophia was placed in an NICU of a major urban hospital. Many of the parents were very young teenage mothers who appeared to be uncomfortable with their newborn babies, as well as ill prepared and equipped to care for them. (We mentioned this group earlier in this chapter.) While Sophia’s field instructor agreed that the adolescents (and their babies) would benefit greatly from an educational group, she advised Sophia that such a group was not practical in this setting. Typically, the adolescents were discharged within a day or two of delivering their babies; they did return to visit their newborns, but they tended not to stay long. The length of the hospital stay of the babies also was problematic in terms of providing an ongoing group. Sophia wanted to facilitate an educational group for teen mothers, but the group she actually led was a weekly group for any teen mother of a baby in the NICU unit. In each session, Sophia answered any questions that surfaced and provided relevant information, but she also encouraged the teens to support and learn from one another.

In each of these situations, the students developed a perceptive understanding of their clients’ needs. Had they had the freedom to create they group they envisioned, it would have been quite helpful to their clients. However, under the circumstances in which the students found themselves, it is likely that their groups as they initially conceptualized them would not have succeeded in meeting their purpose. Table 6.2 presents the tasks associated with forming a group.

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Table 6.2 Professional Tasks in Forming a Group • Identify the group purpose. • Select the type of group. • Compose the group. • Decide upon the temporal arrangement. • Decide on the group size and the length of sessions. • Arrange the room. • Decide upon sole or coleadership. • Create a responsive organizational climate. • Work with and within organizational realities and constraints.

SELECTING PRACTICE MODALITY AND TEMPORAL ARRANGEMENT Practice Modality

Selecting the appropriate practice modality requires consideration of the advantages and disadvantages of each: individual, family, group, community, and organizational and legislative body. Theory- and research-based criteria for the selection of a modality are limited, although the need for organizational intervention, legislative advocacy, and community practice often is relatively clear when clients’ stress is created and/or maintained by the wider social environment. Few explicit guidelines exist for making an informed decision when choosing among individual, family, and group modalities. Client preference and comfort should be the most significant factors, but they may be secondary to other considerations. Practice decisions regarding modality often reflect custom and tradition, as well as agency policies, procedures, and funding sources. In agencybased practice, individual services predominate (Salsberg et al., 2017). Even when group or family intervention would be helpful to clients, these services may not always be available. Selecting a modality is complicated by the fact that social workers and the agencies that employ them often take an either/or approach: the client needs either this modality or that one. Yet, clients often benefit from more than one approach to helping. Thus, flexibility is critical when we first engage with our clients, as well as over time as their needs and circumstances change. Certain clients may be more effectively helped through use of the individual modality. Clients experiencing a crisis who are overwhelmed with emotion, such as rape victims and survivors of a loved one who has been murdered, may

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require the individual attention that is provided by casework. Individuals who face ongoing challenges may be best served by having a long-term, trusting relationship with a social worker. Similarly, clients with histories of past trauma who struggle with present-day challenges also may benefit from ongoing individual work as they face life stressors associated with their past trauma. In many of these instances, clients will require periodic assistance as their life circumstances change, rather than continuous help. Examples include: • Parents of a child with severe developmental challenges may require assistance at the time of their child’s diagnosis, as their child develops and they are faced with a new set of challenges, and as they age and need to work out a long-term plan for their child’s care after they themselves are no longer around. • Clients living with the challenges of chronic mental illness may need continuous help with adhering to their medication regimen and managing their symptoms. They also may need help at various transition points in their lives, including entering or leaving an inpatient psychiatric facility and moving into transitional or independent housing. • Children removed from their home due to abuse, neglect, or both will require assistance during their time in the child welfare system. Over time, this might include help with transitioning into or out of child welfare, managing challenges associated with the reasons for their removal, and “aging out” of child welfare as young adults.

The group modality provides participants with multiple opportunities for support, behavioral change, learning, and coping. A group is particularly responsive to people who share a common set of life events or circumstances or face similar life conditions. Since group members have had similar life experiences, they are apt to be more receptive to fellow members’ suggestions and feedback than to those offered by professionals. The group modality also provides a force with which people can act and gain greater control and mastery over their environments. The following scenarios illustrate how the group modality can be used: • A group for adult survivors of sexual abuse • A group for children whose sibling has died • A group for hospitalized, chronically mentally ill individuals who are transitioning into community living • A neighborhood group formed to address the problem of street crime

The family modality is indicated when life transitional, environmental, and/ or interpersonal stressors affect more than one individual in a family system.

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The family modality may include working with all members of a family, specific subsets or subsystems within a family, or, at certain points, both. Examples of situations in which the family modality would be helpful include the following: • When a child dies, the parents and siblings may need help with grieving the loss. • A high school student has been engaging in assaultive behavior in school. The student describes to the social worker his home life: his mother suffers from alcoholism and his father from drug addiction; both are often absent from the home; an older brother is incarcerated; and the student is responsible for the care of his three younger siblings. The worker believes that the student’s school problems stem from the disorganization and stress that he is facing at home. • The sole wage earner in a family becomes unemployed, and the family is facing homelessness.

Certain situations may make the family modality unsafe for an individual. If an abusive partner is violent and unmotivated to change, couple or family intervention places the abused partner at risk. If an abusing partner is mandated to enter family therapy or agrees only to appease their partner, that partner risks retaliation. In other instances, the social worker will engage in family work by seeing only certain members. For example, a child’s rebellious behavior in school might reflect tension and conflict between his parents. The worker, therefore, may work primarily with the child’s parents to help them work through their difficulties so that they can parent their child more effectively. To illustrate the considerations associated with selecting an appropriate modality, let us consider the case of Ms. Melvin: Ms. Melvin, 55 years old, is depressed and anxious, and she reports sleep and appetite disturbances. She has experienced severe losses in the past six months. Five years ago, Ms. Melvin was awarded physical custody of two granddaughters with cerebral palsy after their mother, Ms. Melvin’s daughter, was found to be abusive. Last year, Ms. Melvin was granted permanent custody of the children. This year, the children’s mother went to court to regain custody. Despite overwhelming evidence in favor of Ms. Melvin, the court recommended that the mother be given temporary custody, with weekend visitation rights for Ms. Melvin. With little counseling or preparation, the children were removed from Ms. Melvin’s home. Six months later, Ms. Melvin’s father died. Last week, her sister died of breast cancer. The youngest of seven children, Ms. Melvin was the caregiver for her aging parents and siblings. She continues to care for her mother, who lives in a nursing home a few blocks away from Ms. Melvin.

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Ms. Melvin is motivated and resourceful, and she displays good judgment. She and the social worker agree on the following goals: (1) work on her grief; (2) establish new relationships with her grandchildren and their mother; (3) find new sources of meaning in her life; (4) pursue possible employment that allows her to use her strengths; (5) develop a new support system to replace the community and agency supports that were related to the care of children with disabilities. Ms. Melvin and the social worker plan to meet weekly and to reevaluate the situation in three months.

At least initially, Ms. Melvin’s sense of urgency may be best met through individual work. She would have the worker’s undivided attention, and it is likely to be easier to schedule frequent individual meetings with her than it would be to organize a life stressor group that would meet her needs. Let us say that there already was an appropriate group being offered by the agency. In this case, Ms. Melvin and the social worker could discuss the possibility of taking advantage of both modalities, since each would offer distinct advantages. Or Ms. Melvin and her worker might conclude that initially, she would like to participate in individual work, but once her sense of urgency diminishes, participating in a group would provide her with ongoing support. However, if Ms. Melvin is a very private and shy individual or awkward in social situations, the group modality might not be helpful. The worker and Ms. Melvin, however, could consider using their time together to help her feel more comfortable in a group setting in the future. At some point, the need for some family work could arise. Although her grandchildren are no longer living with her, Ms. Melvin remains an important part of their lives. Should Ms. Melvin and her daughter disagree or argue about their respective roles, this could undermine the children’s transition back to the care of their mother and negatively affect their emotional well-being. Therefore, family intervention could help Ms. Melvin and her daughter work together for the benefit of the children. Table 6.3 summarizes principles that may serve as guidelines for selecting the appropriate modality. Temporal Arrangement

Social work students should anticipate that the number of sessions that they will have with most clients will be limited, regardless of modality—generally, it will be eight or fewer (Wodarski & Curtis, 2016). Three main reasons account for this reality. First, third-party payers like private insurance, Medicare, and the Medical Assistance Program (MAP) impose time limits on clients’ treatment.

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Table 6.3 Selection of Appropriate Practice Modality Whenever possible, select the practice modality that will be most responsive to client need, choice, and comfort. Select the practice modality that is responsive to the type and definition of life stressors. Select individual modality for people: • Under intensive stress, requiring frequent and immediate contacts • In need of specific, concrete entitlement resources like Social Security, Medicaid, etc. • In need of one-on-one, individual attention Select family modality for: • Life stressors located in family relationship and/or communication patterns • Life stressors located in family developmental transitions, traumatic life events, and other critical life issues Select group modality for people who: • Share a common set of challenging life events • Share a common set of life tasks and issues • Experience isolation or have a stigmatized status • Need to act and gain greater control and mastery over their environments

Second, limited resources often require agencies to cap the number of sessions that clients may have within a particular time frame (often one year). Second, the context and nature of an agency’s services may limit the worker to a single contact with clients. Third, clients themselves often end services early. Some clients simply stop coming and are considered to have terminated prematurely due to lack of motivation, lack of interest, and the like. However, in many instances, it appears that once clients’ immediate needs are met, their sense of urgency is reduced, which leads to them terminating (Gingerich & Peterson, 2013). Clients’ life circumstances also may change, which may prevent them from continuing with services or eliminate the need for services altogether (for instance, a client moves out of the area or a homeless individual secures housing). Research also demonstrates that even when clients avail themselves of services over a longer period of time, the greatest amount of change is likely to occur early (King, 2015; Stulz, Lutz, Kopta, Minami, & Saunders, 2013). Thus, social work students should anticipate that much of their work will be concentrated into a rather brief period of time. When clients utilize social work services over a longer period of time, their use is typically episodic (McKay, 2011; Wodarski & Curtis, 2016). For example, a client may seek (or is required to seek) help and sees a social worker for six sessions. The client then leaves—either with

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Table 6.4 Considerations Associated with Temporal Arrangements Episodic services require

Developing rapid assessment of life issues Developing an immediate plan for focus and direction

Emergency services require

Providing rapid, focused, and immediate services, with frequent sessions as needed until the crisis is past Assuming a directive and structured approach Assessing precipitating factors and identifying significant people involved Assessing cognitive grasp of the situation, the level of anxiety and immobilization, and potential sources of personal and environmental support Inviting the details associated with the crisis event Providing empathic support Specifying issues and focusing on essential, immediate decisions and specification of goals Providing a sense of hope and confidence Engaging and mobilizing personal, family, community, and institutional resources Identifying and working on personal and environmental strengths

Planned short-term services require

Assuming a very active role in the initial interview Specifying one or two stressors Demonstrating empathic understanding Creating a sense of hope Developing an agreement to work on a specific life stressor Setting clear short-term time limit

Time limited

Establishing the termination date in the first session Developing an agreed-on focus Developing preestablished time periods to evaluate progress

Long-term, openended services require

Providing an ongoing supportive long-term professional relationship Sustaining the original sense of purpose and vitality Exploring the potential impact of dependency on the relationship Introducing the concept of time-limited services

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Table 6.5 Considerations Related to Temporal Arrangements: Personal Factors Assess the client’s experience of time according to culture, age, physical, and psychological states. Select temporal arrangements that fit the nature of the stressor, the agreed-on goals, and the client’s own temporal resources and orientations. Provide a quick response to a physically ill client. Communicate a sense of commitment and urgency in contracting with the elderly, avoiding delays or postponements. Provide individuals, families, and groups in crisis several sessions a week, at least until the crisis has passed. Provide young children with frequent, shorter sessions.

the support of the worker or without—and a year or so later, the client returns either with the same problems or with new challenges that have surfaced. Whether the length of time of service is known at the outset or not, the worker immediately involves clients in an assessment of life issues. Based on this assessment of issues and the available resources, workers and clients then will develop a plan for focus and direction in service, ideally at a pace that is consistent with the client’s needs. Research reveals that when workers assist clients in identifying how they can be helpful directly, and from the outset of their work together, clients are more likely to engage in a working relationship and to characterize the worker as helpful (Wodarski & Curtis, 2016). Session length with clients is another consideration associated with time. Social work practice with individual adult clients typically last for one hour. Research indicates that when individual sessions extend beyond an hour, the benefits diminish the longer the session goes on (Stulz et al., 2013). Clients in crisis or with an extreme sense of urgency, however, require more time; therefore, whenever possible, social workers should have some flexibility in scheduling when meeting with these individuals. Children, adults with developmental and intellectual challenges and/or mental illness, and the elderly are likely to benefit from more frequent, shorter session lengths (approximately 30 minutes). When we are engaged in group and family work, sessions are likely to be longer, depending upon the age and the physical and emotional state of the clients. Most adult groups often can sustain work on group tasks in sessions of one-and-one-half to two hours’ duration. Young children and some adult populations benefit from short sessions of less than forty-five minutes. Tables 6.4 and 6.5 summarize considerations associated with selecting appropriate temporal arrangements.

Beginnings

SEVEN

Settings, Modalities, Methods, and Skills

All helping rests on shared definitions about life stressors and explicit agreement on goals, plans, and methods.

DEGREE OF CHOICE

Individuals, groups, families, and communities in need of social work services are potential clients until they accept the agency’s service and the agency agrees to provide it. Engaging potential clients in a social work relationship requires us to consider the degree of choice that clients have when it comes to using our help. Services may be mandated, offered, or sought. Services Imposed or Mandated

Increasingly, social workers encounter involuntary clients who do not want services but are required to accept them (Infocus Marketing, 2017; Rooney, 2009). Mandated social work services vary in their degree of “involuntariness.” Court-mandated services carry prescribed consequences for clients if they fail

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to comply with court orders and are likely to be viewed as coercive. The court’s legal authority is transferred to the agency and the social worker. Compliance becomes the minimal condition for avoiding the status of jailed inmate, probationer, or juvenile offender, or for achieving the return of one’s child from foster care. While legally mandated services are experienced as the most coercive, institutions or agencies can also impose a social work service as a condition for receiving Suboxone to combat a heroin addiction, or for individuals who wish to foster or adopt a child. While institutional requirements may be less restrictive than legal mandates, they still are likely to be viewed as threats by prospective clients. The agency’s purpose can create ambiguity for clients about the extent to which they have a choice. For example, recipients of public assistance might feel compelled to accept a group service designed for job readiness for fear of jeopardizing their assistance grant. Public housing tenants may accept a service lest they be evicted. In these situations, clients may experience our help as being forced on them rather than as something they believe will be advantageous to them. Services that are mandated present social workers with real or perceived ethical dilemmas. These result from the dual responsibilities associated with promoting both client and community well-being. Social work students often approach these dual responsibilities as either/or: one either helps clients or protects the interests of society. In many instances, however, social workers can merge these two responsibilities in ways that are empowering to clients but also consistent with their mandated function and purpose. In child welfare, for example, the social worker’s primary responsibility is the protection of children. To meet this responsibility, social workers attempt to enlist the support of parents or caregivers. As parents’/caregivers’ lives are improved and their stressors and challenges reduced, the well-being of their children is enhanced. When services are imposed, potential clients are likely to have reservations about an organization and practitioner that they view as having power over their lives. Some mandated clients ultimately might acknowledge their need for help, finding the service to be congruent with their own definitions of life issues and aspirations. However, most mandated clients resent having problems attributed to them and being forced by external authority or others to do something that they do not want and do not believe they need to do. They may hide their resentment by superficially cooperating in order to achieve a goal imposed on them by a third party. Others reject the agency definition of their goal or life issue and actively resist the social worker. Therefore, social workers should anticipate that individuals who are mandated to see them might struggle against their power

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and authority. From a potential client’s perspective, the worker may represent a serious threat—even an obstacle—to their own aims. Social workers in mandated settings often commit one of two common practice errors. Because they are intimidated or angered by their clients, they avoid dealing with the question of legal, organizational, and professional authority, or else they set out to build a relationship without addressing the mandate or the client’s anger. In both cases, the worker fails to recognize that the relationship can emerge only when the mandate (and the feelings that it generates) are dealt with directly. In both cases, the difficulty in engaging a distrustful and angry client is increased. If the social worker also becomes angry, unnecessary confrontations may follow. The misuse of authority and power increases client distrust and resistance. The task is to turn formal authority into professional influence. Social work students must learn to be direct and honest about the source of the mandate, their own authority and responsibility, limits on confidentiality, potential consequences of noncompliance, and definitions of noncompliance. The guiding principle is to provide the least intrusive service. Ethical practice requires social workers to use their authority to provide resources to mandated clients as they would for nonmandated clients without imposing personal standards that are not part of the mandate. Professional directness and honesty reduce mistrust, thwarted expectations, and resistance. Social workers must demonstrate warmth and caring if the client is to hear their description of the services being offered. A professional explanation of the services must be mediated by compassion for the client’s predicament and life stressors, over which any semblance of control is being lost. Also, the description of the services should fit the client’s perception of reality. For example, “You feel the parole officer is hassling you” may more accurately reflect the mandated client’s perception than “Your probation officer believes that you have a drug problem.” The aim is to actively engage the client in an area in which a commonality of interests exists. At the same time, nonnegotiable legal requirements and agency policies must be distinguished from negotiable rights, choices, and options. Common goals often are best described as “helping clients get the agency—and us—off their back,” “helping neglectful or abusive parents to improve their parenting, so they will be free of agency monitoring,” or “helping probationers or parolees to meet the conditions for changing their status.” Working with mandated clients often challenges workers’ ability to empathize because the mandate may result from criminal or other behavior by these clients that is viewed as socially unacceptable. Remembering the distinction

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between should and is helps the worker approach the mandated client in a nonjudgmental way, such as the following statements: • The mom (who lost custody of her children) should not have left her children alone so she could get high, but she did. Her addiction is more powerful than her concern for her children. • The adolescent should not have assaulted and robbed the elderly couple, but he did. He has grown up in poverty, seen friends and family members murdered, and dropped out of school, and he sees no future for himself. His actions reflect what he has learned to do to survive and his alienation and despair.

In these instances, and many more like them, workers need not agree with or condone their clients’ actions. Rather, they must understand—without judgment—the context within which these actions occurred. The stages of change model discussed in chapter 5 has relevance for our efforts to engage mandated clients. We should assume that most mandated clients are most likely in the precontemplation stage. They do not see themselves as having a problem other than the mandate to see us. When we start with their definition of the problem, we may be helping mandated clients move from this first stage to the second one, contemplation—from “I don’t have a problem” to “I have a problem [the mandate] and I want it to go away.” Consider the following case: George R., an African American 15-year-old, recently moved to a large urban area with his mother and two younger brothers. They live in a low-income neighborhood that is known for drug and gang-related activity. His mother divorced her husband 10 years ago, and George sees his father only infrequently. Since his arrival in the new city, he had been repeatedly involved in fistfights at school. When he was suspended from school, he threatened to kill school personnel. Following what law enforcement described as an “unprovoked attack” on a smaller boy, George was to be taken to juvenile detention. When handcuffs were used, however, he became so out of control and threatening that he was taken instead to the psychiatric ward of the local public hospital, where he remained until his court hearing. He was diagnosed with oppositional defiant disorder, and commitment was recommended. However, a final decision was delayed because his mother agreed to seek outpatient treatment for George and to take a leave of absence from work to care for him at home. He was ordered by the court to seek treatment from a community mental health center and stay away from school until a second hearing in two months.

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George’s first interview was with Gwen, an older, white social worker who had worked at the mental health center for many years. Gwen described her first encounter with George as follows: Before I could even introduce myself, George walked in the office, sat down in a chair, and said: “I’m not coming here, I don’t care what they do to me, I don’t care, I’m not crazy! Let them send me to a state hospital, I don’t care.” I cut in and calmly said, “Okay, you’re really pissed off. Why don’t you tell me what happened to you?” His story was incoherent and interspersed with threats to kill the principal, the judge, and the school counselor. He insisted that he did not start the school fights, and that everyone was against him. He described the police, the handcuffs, and the days on the psychiatric ward and kept repeating, “I don’t care.” I said, “Handcuffs and the psychiatric ward . . . that must have been so scary.” He said, “They were going to send me to the mental hospital. That’s like prison. I’m not crazy. I’m not coming here, I don’t care what the judge says.” I said, “George, I understand you don’t want to be here, that you just want to be left alone. But you might not have that choice. It might be here or the hospital. I’m hoping that we can help you have more control over what happens when you go back to the judge in a couple of months. You might not be able to get rid of me during that time, but we might be able to keep you out of the hospital in the future.” I smiled as I said this. George looked up at me when I made this last statement and seemed interested, so I continued, “So, I got a lot of information about you and about what happened. But I also learned about all the hurts you’ve experienced. It sounds like, when you were a little kid, other kids picked on you. You must have been very lonely?” Initially George was silent, so I said, “That must have been rough.” He looked at me and then said, “So what if I got bullied? What’s it to you anyway? What do you know about what it’s like?” I said, “Maybe you’re thinking that some old white woman like me can’t understand a black guy like you?” George remained silent, but he did look at me and nodded slightly. So, I gently added, “The report also describes the hurts from your father, the beatings . . . you weren’t safe anywhere, it seems.” At that point, George stopped me and said that he wanted to talk about grade school. He described how the bigger boys would tease him for how he dressed. He jumped to the present, describing his loneliness. He was out of school, and a month ago he’d been told to leave the rec center and never come back. He added sadly, “I got no friends, see? Nobody wants me around, but I don’t care.” I responded, “It sounds like you’ve been hurting for a long time, and it feels like no one cares. Like you’re just another black kid in trouble with the law.” George agreed.

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Table 7.1 Skills and Considerations: Beginning with Mandated Clients • Prepare to be perceived as a potential threat to clients. • Anticipate and acknowledge the clients’ reluctance and resistance. • Openly discuss the source of the mandate, potential consequences for the client’s noncompliance, and the limits of the worker’s professional authority and confidentiality. • Specify the conditions for termination of the mandate. • Share available information. • Acknowledge and invite clients to share their view of the problem. • Coconstruct cooperation by asking clients to consider how to eliminate the mandate.

The social worker realized that George was in the precontemplation phase. Her acceptance and skillful use of empathy helped alleviate some of his fears and anxieties about both her and his situation. She was not intimidated by George’s anger, nor did she take it personally. Instead, she acknowledged and responded to his feelings. Gwen recognized the role that race and social position played in George’s experiences. She also understood why he might approach her with suspicion and hostility, given her more privileged status. Her actions paved the way for him to move from precontemplation to contemplation. Before we leave this discussion, we must remind readers that there will be times when we may do everything possible to enlist a mandated client in a working relationship, but we still may not succeed. This does not mean we—or our clients—have failed. It means that clients are not yet ready to accept the help that we have offered. However, if we have interacted with our mandated clients honestly, openly, and with acceptance, we must consider that in the future, if and when they are ready, they will have the courage to reach out based upon their positive past experience with us. Table 7.1 identifies essential skills and considerations in beginning with mandated clients. Services Offered

Social workers and their agencies may engage in outreach, whereby they inform individuals of the available services that they may need. When an agency decides to offer a service, someone has decided that a need exists or a source of funding has become available to expand service options. Typically, potential clients who respond to an offer of services are doing so because of some sort of perceived life stressor. However, potential clients’ perceptions of their need and the client need represented by the offer of service may not be identical.

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A teacher, for example, may refer a child to you for being a “troublemaker.” While the teacher calls the child troublesome, the child may see himself as being picked on. Similarly, while developmentally challenged young adults may be reluctant to accept services that focus on their intellectual disabilities, they may be willing to engage in a discussion of how their social status affects their lives—teased for being slow, treated like a child, or labeled as “retarded.” While adults may resist services offered to “alcoholics,” they may accept that alcohol has created problems in their lives. Engagement of potential clients responding to an offer of services requires that we validate their perception of their life issues, based upon using anticipatory empathy. This increases the likelihood that the potential client will accept the agency’s services. Social work students often express discomfort about directly identifying clients’ potential life stressors when offering an agency’s social work service. To students, it feels presumptuous to tell people that they may need the help of a social worker. Being indirect and focusing on forming a positive relationship with the intent of easing gradually into the “serious” business later feels less risky. Ironically, when the worker is hesitant and indirect, the anxiety of prospective clients increases as they try to figure out the worker’s hidden agenda. In contrast, a skillful, direct offer of service can reinforce potential clients’ belief that outside help is needed. Sometimes it is the offer that awakens this realization in the client. Yet an offer of help may also create ambivalence about accepting it. This ambivalence will need to be explored as well. In offering a service, social work students must learn to develop a clear, concrete description of the agency and of the available social work services and professional purpose, without jargon and with due attention to the potential clients’ perceptions, values, and life courses. For example, suppose that you were assigned to reach out to a woman who is very depressed over a recent transfer to a new job. If you were the prospective client, contrast the statement “The focus is to restore your sense of self-esteem” with “The focus is on helping you to deal with your new job pressures and the increasing strains at home with your husband and children.” Identifying specific, concrete life issues that occur in daily human interactions helps both client and worker to be less overwhelmed and more hopeful and focused in their work. The worker suggests how the offered service connects to the client’s life situation. People who are well informed about what is offered are less apt to fear a hidden agenda, such as a practitioner describing one service while intending another. Table 7.2 summarizes the skills of offering a social work service.

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Table 7.2 Skills of Offering a Social Work Service • Define and describe the agency’s function and services. • Describe social worker’s function. • Describe the service being offered. • Identify the client’s potential perceptions of his or her life issues or needs. • Reach for the client’s doubts, hesitations, and ambivalences. • Establish the priorities in the work being done with the client. • Specify client’s and social worker’s respective tasks and responsibilities. • Specify temporal arrangements for the intervention.

Services Sought

People usually seek social work services at the point when life stressors have become unmanageable. The act of seeking help can itself be another stressor. Cultural and societal norms that value self-reliance may lead people to view asking for help—particularly from an outsider/stranger—as a sign of weakness, which creates further stress. Family and cultural norms also may equate asking for help as a betrayal, as “airing dirty laundry.” A sense of shame or fear of how one will be received by the social worker mingles with hope that one’s needs would be met, the stressors ameliorated, and the stress eased. Even potential clients who seek out our services will face the first session with at least some measure of ambivalence. Since people usually seek help when they are at their wits’ end, timely professional availability is essential. Service delayed can lead to service declined. With services sought, the social worker invites prospective clients to tell their stories and identify their specific concerns and needs. We now turn to the skills used to explore and clarify a prospective client’s narrative and to develop mutual agreement. The skills associated with helping clients tell their stories are presented next.

CORE SKILLS ILLUSTRATED

Regardless of potential clients’ degree of choice, there are core skills that are helpful in developing a mutual focus and engaging clients in a working relationship.

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Explanation of Purpose and Role, and Reaching for Feedback

The offer of service is not formalized until potential clients and the worker reach an explicit agreement about focus, means, and mutual responsibilities. The worker provides a clear statement of purpose and role and elicits potential clients’ feedback in order to ensure that the worker and clients are on the same page. We begin with a nonjargonized, concrete description of the agency and of the nature of the help that we can provide as we reach for prospective clients’ reactions. Consider Cheryl, a 42-year-old who became very depressed over a recent unwanted transfer to a new position with her company and increasing discord in her family. Cheryl’s husband made the initial contact and requested that the local mental health center reach out to his wife. The worker explains to Cheryl her role and purpose as follows: “Your husband contacted us about your being upset over being transferred to a new position. We would like to help you deal with the pressures of your new job and the increasing tensions that seem to have surfaced at home with your husband and children.” This offer of service identifies specific, concrete life transitions that that are creating stress for Cheryl, which helps both client and worker to be less overwhelmed and more hopeful and focused in their work. The offer also clarifies the information that the worker already has about Cheryl, as well as its source—her husband. It is possible that Cheryl’s view of the situation and that of her husband differ, and it is important that the worker convey that she wants to hear Cheryl’s story. Our explanation of role and purpose also must be tailored to the developmental and intellectual levels of our clients. For example, Ms. Carly, a school social worker, will be seeing a second-grader who is referred to her by his classroom teacher for behavioral problems with peers. When she meets with Jose for the first time, she says, “Hi, Jose, my name is Ms. Carly, and I’m a school social worker. Do you know what a social worker is?” Jose shakes his head no. The social worker continues, “Sometimes kids have things on their mind, like things happening at home, or a teacher yelling at a kid for not following directions. Social workers help kids with things that bother them, so that they are able to learn at school and have fun.” In a day program for adults with intellectual challenges, the social worker is conducting an intake interview with a new client who will be receiving job readiness training, as well as preparation for independent living. After shaking hands, Mark, the social worker, introduces himself and his role and purpose by

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saying, “Hi, Samuel, my name is Mark Kenner, and I’m a social worker here at the agency. I understand that you’re ready to move out of your mom and dad’s home?” Samuel nods his head yes, and Mark continues, “That’s awesome! I’m the guy who would like to help you make that happen! We can work on helping you get a job, so you’ll have your own money. And also work on finding a place for you to live that makes you feel safe but also gives you freedom to do what you want. How does that sound to you?” Social workers must always be direct and honest about their purpose and role. This is critical when services are offered or mandated. For example, in a psychiatric hospital serving adolescents and their families, social workers interviewed parents with the stated purpose of securing a developmental history of their teenager. The latent-but unstated-purpose was to engage parents in treatment. In other words, parents were offered services both indirectly and covertly. A social worker employed in this setting describes the challenges that he faced when trying to engage the Daltons in a working relationship. The hospital’s treatment team had already determined that the stress from the Daltons’ marital problems was contributing to their son’s mental illness. The worker, however, does not acknowledge this when he meets with the parents: In our first session, I explained to Mr. and Mrs. Dalton that as the social worker, I’d be meeting regularly with them to secure a developmental and family history and information about recent events in their son’s life. I also explained that we inform parents about their child’s progress, answer any questions they may have, and seek out their help with discharge plans. Mr. and Mrs. Dalton accepted my invitation and agreed to provide the necessary information. In subsequent interviews, however, they resisted my efforts to identify and address their marital problems. I had never acknowledged this additional goal of our meetings. I was too uncomfortable to state directly that I wanted to use our time together to explore the role they might play in their son’s mental health problems.

Parents often worry about the possible role that they may play in their child’s illness and are likely to assume that they are at fault or will be blamed. Instead of encouraging the Daltons to engage in a partnership with him to help their son, the worker’s hidden agenda mobilized their anxiety and defenses and closed off any possibility of engagement. Contrast the Daltons’ experience with that of Mr. and Mrs. Parker, a couple who identify as African American and whose daughter, diagnosed with schizophrenia at age 16, was hospitalized after attempting to strangle her 4-year-old foster sister. The worker describes her first interview with the parents:

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I discussed the purpose of our getting together and mentioned that parents often have worries about how and why their children developed a mental illness and also what will happen to their child in the hospital. They also wonder what to expect when their child goes home for the weekend. I said I would like to help them with any worries and questions they may have, and at the same time, I needed their help with our efforts to understand Linda’s illness. Mrs. Parker responded that as a baby, Linda had no troubles or tantrums. “We always thought she was a happy child and it’s hard for us to understand what went wrong. I want to know what went wrong. What caused this to happen? Can you tell us, or don’t you know? Or do you know and won’t tell us?” I replied, “We don’t really understand how this came about, but I will always share with you everything I know. With schizophrenia, there is usually no single factor, no single experience that we can point to as the cause. There are biochemical and genetic factors, which are still not fully understood. There may be emotional experiences that only Linda perceived to be significant, yet they could have triggered this reaction. She might have felt pressure that led to a lot of anxiety, and we need to understand that too.” Mr. Parker noticeably relaxed and shared some recollections of when he began to suspect that Linda was having trouble.

This direct statement of purpose, coupled with the worker’s observation that all parents have natural worries, was both reassuring and welcoming. It relieved the parents’ fears of negative judgments and blame and encouraged them to enter into a partnership with him. As we noted, inexperienced workers often wish to focus on forming a positive relationship, with the intent of easing gradually into the “real” work later. This erroneously assumes that creating a good relationship between worker and client is the goal of the work. The working relationship develops only when potential clients have a clear understanding of the services we are offering, believe that we want to understand what they are telling us, and feel comfortable sharing their stories. A worker’s discomfort is likely to be heightened with mandated clients. The worker can address this problem by preparing a nonjargonized statement of service and an explanation of the mandated nature of the work. This includes being direct and honest about the source of the mandate, the nature of our authority and responsibility, limits on confidentiality, potential consequences of noncompliance, and definitions of noncompliance. The challenge is to work within the constraints placed upon us (and our clients) by the mandate to forge a meaningful alliance.

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We now continue with Gwen, the social worker in the community mental health center, and her attempts to engage her mandated client, George, in a working relationship. Readers will remember that through an effective use of empathy, she established a tentative connection with George, conveying concern about his painful and lonely childhood. Engaging him in a working relationship required that she clarify how she could be helpful and acknowledge the nature of the mandate. Therefore, after the exchange presented earlier, Gwen recounted: “Being alone can make a guy pretty angry, make him lash out at everyone and everything. And the move to a new city probably just made things worse?” George nodded, so I continued, “So, how about if I tell you what this is all about? Can I do that?” Again, George nodded. “I know it might not seem like it, but the judge actually is giving you a bit of a break here. She could have sent you back to that hospital, but she’s hoping that if you see me, we can help you get control of your feelings, so you don’t get in trouble at school or in your neighborhood. Does that make sense?” George said it did, so I continued, “I want to be clear with you, okay? I will have to provide a report to the judge every two weeks. I have to let her know that you’re keeping your appointments. I don’t have to tell her what we talk about, but I do have to let her know you’ve been coming. And—and this is really important—if you don’t keep the appointment, I have to let her know right away. I can’t say what she would do, but it’s possible that she would send you back to the hospital or the detention facility. I’m sure you don’t like hearing that, but that’s the reality right now.” George said, “Man, this is fucked up. It just ain’t fair!” I said, “I know it feels that way, and it does suck not to have a lot of control, but that’s the way it is for now. But you do have some control over what happens when you go back to court. And that’s where I come in. You and I can work to help explore your hurts and to manage your feelings, to keep you from getting into trouble. What do you think?” George said, “Well, I guess coming here is better than being locked up with a bunch of crazy people.”

George may not yet be a completely willing participant in his working relationship with Gwen, but he is well on his way, due to the worker’s empathy, honesty, and directness. This example illustrates an important aspect of clarifying one’s role and purpose, which is checking with potential clients to make sure that they understand our explanations. We want to make sure that we are on the same page as our clients and that their understanding of our social work service and role is accurate. The worker suggests how the service connects to clients’ life situations and invites them to respond in terms of that connection. Essentially, the worker is

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asking, “Does this make sense to you?” and “Does this sound like something that would be helpful to you?” Providing a straightforward explanation of how we can help promotes safety and trust, both of which are essential elements of good working relationship. The working relationship also should be presented to clients as a partnership. The worker is not there to do something to clients. We are there to work together with our clients to resolve the life stressors that brought about the need for help in the first place. A final consideration associated with clarifying role and purpose is unique to social work students’ roles as interns. Consistent with the Code of Ethics of the National Association of Social Workers (NASW), agencies must clarify to their clientele that social work students are not regular staff. Agencies should be open and direct about their training function and present their students as supervised interns. Students’ explanation of role and purpose includes their status as interns, and students must be prepared to address any concerns that clients may raise associated with their status. Collecting Relevant Information

With clients seeking services, after introductions, the worker invites clients to tell their story and identify specific concerns and needs they have. In some settings, the structure of the first session (or the early part of a single session with a client) will be flexible, which allows the worker to ask open-ended questions. The worker may say, “Tell me what brings you here.” The question provides some direction, but it also gives potential clients latitude in replying. Inviting clients’ perspectives and narratives is equally important to mandated and offered services. The worker may only need to use minimal verbal encouragers to invite elaboration, like “Uh huh,” “Ah,” and “Mmm” and phrases such as “I see,” “Go on,” and “I understand.” The worker’s verbal comments must be accompanied by nonverbal behavior that conveys interest, warmth, and acceptance. This includes body posture, such as leaning in, eye contact, tone of voice, and facial gestures. Mrs. Carlini, a 32-year-old Italian American, sought help from a family service agency. She left her husband a year ago when he told her that he was seeing another woman. She described herself as feeling depressed, and then she began to tell her story. The student social worker describes their first meeting: Even though she’d had a good weekend, Mrs. Carlini told me she still had to go home alone and face the reality of her husband’s leaving her for another woman. What made it worse was her feeling that she had failed as a wife, as a lover, companion, source of support, and mother since her children would no longer have their father

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at home. She felt alone and pessimistic. She said that she can’t get it out of her mind that she was to blame. “I’m even a failure at getting better.” I responded nonverbally, occasionally nodding or making short comments to show that I understood what she was saying. She then said she was thinking about her expectations of what a woman was supposed to do—get married, run a household, raise kids, give support to her husband, and that she must have failed in some way for her husband to leave her for another woman. I said that the last few months have been very painful for her, especially with thoughts of failure on her mind. She said she worked hard in her marriage to make things work, but they didn’t. And then, all of a sudden, he told her he was seeing someone else. I responded, “He hurt you very badly.” She agreed and added she had hoped that her husband would be willing to work on whatever problems existed in their marriage. She realized that he might think about leaving but never expected him to go so far. For that to happen, she really must have “screwed things up.” I said, “Mrs. Carlini, you are putting a tremendous amount of responsibility onto yourself, assuming that everything was your fault. It takes two to make a marriage work and two for it to fall apart.” She nodded and said others tell her the same thing, but she can’t seem to get rid of that idea.

As Mrs. Carlini speaks, the student worker picks up nonverbal messages that might indicate anxiety, depression, and guilt. The student notes what the client emphasized, what she left out, and discrepancies between verbal and nonverbal communication, and considers the client’s affect. When potential clients actively seek service, their sense of urgency—like Mrs. Carlini’s—may be strong enough that minimal, supportive interventions suffice. In these situations, “less is more”: the worker’s constructive use of silence encourages clients to freely and openly discuss their concerns. In many practice settings, social workers have much less flexibility in their initial interview with clients. Agencies often require that social workers engage in a more formal intake procedure, which is likely to necessitate asking a prescribed series of questions about potential clients’ background, racial/ ethnic identity, marital status, and income and address (to determine eligibility for services). These questions will typically require short, yes or no replies. Closed-ended questions like these are restrictive, and interviews that rely upon them can take on an investigative flavor. The worker maintains substantial control of the interview and potential clients follow the worker’s direction, rather than the reverse. Occasionally, however, closed-ended questions can

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help potential clients get started and can also slow down premature “spilling” and overconfiding, Social work students often struggle when they are required to collect information in this more structured manner. We suggest that this discomfort results from an incomplete understanding of their role and purpose at this early point in the work. Social workers will have difficulty to be helpful to potential clients until they have obtained whatever information is deemed necessary by the agency in which they practice. When we view our work as a partnership, it becomes easier to collect necessary information and display interest in and warmth toward clients. One way to do this is to explain to clients the reasons for our questions, and, if needed, convey understanding that the questions may be tedious. Clients—even those who have sought assistance—may have difficulty identifying what they need help with. Potential clients may recognize their distress but remain unclear as to its source. Alternatively, clients may identify sources of distress that differ from the assessment that the social worker is developing. For example, Mrs. Carlini views her problem as depression resulting from her having failed as a wife. In contrast, the worker is developing an assessment in which Mrs. Carlini’s depression reflects her belief that she is solely responsible for her husband leaving her. Research indicates that from the beginning, clients value and benefit from the social worker’s direction and guidance (Wodarski & Curtis, 2016). Therefore, the worker should have questions ready to guide the client’s reflections on the need for assistance and be prepared to offer insights into and feedback about what the client has shared. For example, the student worker validates Mrs. Carlini’s perspective but provides her with an alternative way to view her situation—one that places less responsibility on her for the marriage ending. The worker often will need to use structuring questions that provide direction for potential clients’ narratives. The worker introduces stressors based upon the services provided by the agency and the clients’ reasons for seeking help or having services offered and mandated. The worker also uses questions to encourage clients to elaborate upon and clarify their concerns. In the early presentation of their stories, potential clients might include subtle, indirect, or qualified messages, such as “I thought he was a man of integrity,” “He beats me, but it’s not so bad,” or “I’m kind of pleased with what she has done.” By repeating a key phrase, “Not so bad?” “Kind of pleased?” the worker highlights the hidden message to develop a more accurate assessment of what clients are saying. Rephrasing and paraphrasing in the form of a question, “Are you saying that for once she  .  .  .?” “Does what I am hearing mean that he is

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doing  .  .  .?” communicate the worker’s interest in understanding the hidden message. These skills also encourage further elaboration. Rephrasing and paraphrasing skills can allow us to deepen our understanding of our clients, but they must reflect workers’ sincere desire to understand what potential clients are telling them and convey genuine concern. Otherwise, clients will immediately experience the worker’s lack of authenticity. A “textbook” way of rephrasing and paraphrasing would be, “What I hear you saying is . . .” If this statement is not an honest attempt to ensure that the worker is on the same page as the client, it will come across as rehearsed and inauthentic. Clients will assume that the worker has not heard them or listened to them at all. Social work educators typically caution students to avoid asking “why” questions. The authors concur that these questions may be experienced by potential clients as challenges or accusations, and therefore they may encourage self-justification and rationalization. The question “Why?” also may be unanswerable and can block potential clients’ spontaneity in discussing their situation. At the same time, when the worker prefaces a “why” question with the reason for asking it, the client may reveal important and useful information. Asking why also can provide clients with the opportunity to think about themselves and their situation, and can promote insight. In work with adult survivors of sexual abuse, the coauthor often asks clients why they take responsibility for what happened to them, rather than blaming the individuals who abused them and/or didn’t protect them. The question usually goes something like this: “So, Pat, I’m curious about something. You seem to think that you are the one who caused your dad to abuse you, that something you did caused him to molest you. I’m wondering why, since you were the child and he was the adult?” Whether a client experiences this question as a challenge or as unanswerable depends largely upon how it is asked, as well as upon the worker’s ability to attend to clients’ verbal and nonverbal communication in response. Clients’ responses might indicate defensiveness or embarrassment that they cannot answer the question. In these cases, the worker might clarify the question and why she is asking it. Whether the early interactions between workers and clients are structured or unstructured, clients may stray off topic, switch focus, and in other ways not provide the information that is needed to begin a working relationship. In these instances, the worker will need to redirect and refocus the discussion. Students often are reluctant to use this skill because they worry that clients will experience this as rudeness. However, until we have a clear sense of what potential clients need help with, we cannot be helpful, nor can we form a meaningful relationship with them.

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Straying off or switching topics may reflect unwillingness on the part of clients to engage with their pain or with us. This is especially likely to occur when services are offered rather than requested by the clients, and particularly when they are mandated. This unwillingness may be related to shame and embarrassment about the reason for the need for assistance, ambivalence about asking for or accepting help, and questions about the worker’s ability to be helpful based upon cultural differences, the nature of the problem with which the client is seeking help, and the like. Whatever the reason, the worker should be prepared to address signs of avoidance directly. After the potential client has shared relevant material, the worker summarizes the client’s concerns and life issues and asks for client feedback. This summary will include the worker’s own observations about what they have learned and observed. A statement such as “Let me pull together what we have talked about to make sure I understand . . .” provides an opportunity for clients to amplify messages not heard by the worker, clarify, correct the worker’s understanding, take stock, and continue the exploration if needed. In chapter 6, we introduced readers to Sarah, a hospital social worker who was responsible for developing a discharge plan for Claudia Anderson, a 60-year-old African American patient who had to have her leg amputated due to diabetes. Readers may remember that hospital staff had defined Ms. Anderson as a “difficult patient.” In the excerpt that follows, Sarah meets Ms. Anderson for the first time to offer a social work service. Sarah knocks on her patient’s door and explains that she is from the social work department, and asks if she may come in and talk with Ms. Anderson. She enters the patient’s room, asks permission to sit down, and begins: sarah: Good afternoon, Ms. Anderson, my name is Sarah Wells, and I am one of the hospital social workers from the Department of Social Work. May I sit down? Ms. Anderson nods in the affirmative. sarah: I understand you have gone through a real rough time, so I am here to see how I might be helpful to you, since we will be discharging you in about a week. Another thing I’d also like to help you with, if you think it’s needed, is the sadness you may be feeling about the loss of your leg. Also, we can work on any problems you have had with staff.

Readers will note that Sarah refers to her client as “Ms.” and herself by her first and last names. While subtle, this conveys respect for the patient, who is in fact old enough to be Sarah’s grandmother. Sarah also immediately provides a

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brief explanation for her visit and acknowledges the stress that the client may be experiencing. Sarah continues: sarah: What I am hoping is that you and I can decide on a plan that gets you out of the hospital and into a comfortable and safe place that allows you to recover. Since you’re going to be with us for more than a week, I also want to make sure that you feel comfortable with our medical team. How does that sound to you? ms. anderson: Okay, I guess. (Does not look at the worker) Silence. sarah: A lot of my patients wonder how this young “girl” can possibly help them (smiling). Maybe you’re wondering that? Ms. Anderson nods. sarah: You’ve gone through a really rough time, losing your leg. I’ll bet you would like to get out of here and get to someplace more comfortable? Ms. Anderson nods. sarah: Well, that’s what I can help you with: figure out a plan for you to leave here and help you deal with this new reality of yours. I’m hoping you’ll give me a chance to do this? ms. anderson: I don’t got no leg no more . . . How am I going to get around? Who’s going to help me with things? Can I go home? Do I have to go to a nursing home? I don’t want to go to no nursing home with all them old people (starts to cry) sarah: (Pulls chair close to the bed, leans in, and pats Ms. Anderson on the arm) You have a lot on your plate, and it feels overwhelming. But that’s why I am here. To help you get the help you need and to eventually get you settled into a living situation that works for you. So, how about if we figure this out together?

In addition to a clear explanation of her role and purpose, Sarah uses several other skills to encourage Ms. Anderson to accept her offer of help and enter into a professional relationship. She attends to her client’s nonverbal cues and puts them into words. Sarah displays a willingness to raise sensitive or taboo subjects: Ms. Anderson’s reservations about Sarah, the loss of a limb, and her fears about her future. Sarah also uses another set of skills as she collects information, which facilitates client disclosure and promotes the discussion of difficult topics. She tolerates, or waits out, silence and then reaches for its meaning. When clients fall silent, particularly before their worker has had a chance to get to know them and become familiar with their ways of communicating, this may be threatening and anxiety producing. Research suggests that in most instances, workers’ anxiety is

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not warranted, since it is likely to be an indication of reflection and thoughtfulness (Ladany, Hill, Thompson, & O’Brien, 2004; Sharpley, Munro, & Elly, 2005). Silence is uncomfortable for most of us, but skillful social workers learn to be cautious about rushing to fill it with “noise”: irrelevant questions, empty reassurances, and the like. Judiciously waiting it out allows clients time to think. Social workers balance allowing the productive use of silence against silence that is counterproductive and leads to client anxiety or discomfort, or a battle of wills as to who will break the silence first. Timing is critical: neither to respond too quickly and thus cut off thinking, nor too slowly and thus increase anxiety. Unfortunately, our own discomfort leads us away from silence and from the applicant’s concern that it expresses. Shulman (2012) found that the skill of reaching for silence is one of the least used of all the skills that he studied. He also found that in the face of silence, workers tended to change the subject instead of exploring it. When we are uncertain about the meaning of a silence, we can reach directly for its meaning. For example, “I wonder what you are thinking at this moment?” invites further exploration. Sarah uses the skill of reaching for the meaning of silence, but she does this subtly. As a more experienced social worker who is comfortable addressing the questions that her patients may have about her, Sarah puts into words what she thought Ms. Anderson’s silence might mean. In doing so, Sarah is giving Ms. Anderson permission to acknowledge her reservations, which enhances the likelihood that the client will take her up on her offer of help. When services are mandated, it becomes even more likely that clients will be reluctant to engage with us, as we saw in how George initially responded to Gwen. We have discussed the ambivalence that even voluntary clients may experience about getting help. In the case of mandated clients, though, they are likely not to experience much ambivalence—they believe that there is no problem at all, at least not with them. Others who are bothering them are the real problem—those who are requiring them to obtain help and those of us who are going to be the helpers. Mandated clients may be required to see us, but that does not mean they are truly clients. When services are mandated, we acknowledge what we already have been told about our clients, but we also must allow them to tell us their stories in their own words. We need not agree with their stories or accept them as accurate, but we want to convey to clients that we are interested in their perspective, as Gwen did in her initial interview with George. In another example, Sylvia, a 21-year-old Puerto Rican social work student, is placed in the office of the public defender. She has one 30-minute, in-person meeting with each of her clients prior to their court appearance. Her clients are

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mandated to attend the meeting, but they can—and often do—choose not to answer her questions, remaining silent throughout the meeting. The purpose of the meeting is to collect information about the client that she will ask the court to consider prior to sentencing. Sylvia’s initial encounters with clients were quite upsetting to her, as her clients—all young Hispanic or African American men—in her words, did nothing but “hit on” her. She kept asking herself, “Why would they give me so much grief when I am the only one who can help them when we go to court?” With the help of her field instructor, Sylvia developed a deeper appreciation for what her clients’ behaviors might mean, which informed her anticipatory empathy and enhanced her ability to engage with and help them. Sylvia came to realize that her clients—who saw themselves as powerless in the face of social and white privilege and their involvement with the criminal justice system—had few ways to express their bitterness and anger. One of those ways was to “hit on” her. It was counterproductive to their interests, but it provided a momentary relief to the bleakness of their lives. In the following excerpt, which occurred midway through Sylvia’s placement, she met with Lloyd, a 29-year-old African American charged with assault. Lloyd already has served time in prison for breaking and entering and had several other convictions for more minor offenses. The current charge stems from an argument that he had with his stepfather. Lloyd dropped out of high school and works at a fast food restaurant. He lives at home with his mother, stepfather, girlfriend, and his two young children. His is the sole source of income in the household, since his mother is disabled and his stepfather was recently laid off. Sylvia begins the interview by introducing herself and explaining the purpose of her meeting to Lloyd. The following exchange then occurs: Lloyd is silent, rolls his eyes, and “eyes her” up and down. sylvia: So, Lloyd, I’m thinking that you may have some questions for me? lloyd: (looks at the ground, fidgets in his seat) No, no I don’t, Miss whatever your name is. sylvia: Smiling. My name is Sylvia Guzman. lloyd: Okay Ms. (said in an exaggerated tone) Guzman. What’d ya need to know? sylvia: Lloyd, I get that you don’t want to talk to me, probably think I’m young, I’m inexperienced, and—even worse, I’m a girl (smiles). But you’re in a tough spot. I also get that you might not believe I can help you. Maybe you even believe that no one can help you. But how about you give me a try? See if we can come up with some information that might help you in court? Keep you from going back to prison? Maybe we can start with your version of things? What happened

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from your standpoint? What I’ve been told is that you assaulted your stepfather. What happened? lloyd: Yeah, that’s what them cops say and my moms. Fact is, her husband started beating on her—it ain’t the first time, neither. I stepped in, tried to stop that SOB, hit him a few times. Trying to protect my mama. So they arrest me, and she don’t even tell them cops what he did to her. She refused to press charges! sylvia: Wow, that’s awful! Sounds like you were trying to protect your mom, but then she wouldn’t even back you up.

Sylvia begins to earn Lloyd’s trust when she asks him to tell her what he happened, from his perspective. Lloyd initially communicates his concerns about Sylvia mostly through his tone of voice, eye movements, and body language. He says he is willing to work with her, but nonverbally he seems to be saying that he is not ready to do this (or perhaps he does not think it will make any difference). Since Sylvia has only this one brief interview to do her job, she has no choice but to directly address his avoidance. This requires her to use empathy skills, which we address next. Displaying an Understanding of Client Feelings

In a first session, social workers will need to balance the collection of information (being systematic) against the need to empathize with, or be responsive to, potential clients (Doel & Marsh, 2017). Students are particularly likely to struggle with this balance because they view these tasks as mutually exclusive: one either empathizes with the client or obtains the information needed to initiate and provide services. Skillful social workers empathize with clients at the same time as they collect the required information. This requires the use of core empathy skills— acknowledge and verbalize client feelings, reach for specific feelings, make supportive statements, and validate, legitimize, and universalize client feelings—balanced against the skills associated with the collection of information as well as redirecting the client and linking client feelings to the presenting problem. Students learn to be responsively systematic and systematically responsive (Doel & Marsh, 2017). Continuing with Sylvia’s work with her mandated client, Lloyd, the following exchange occurred: lloyd: You mean well, Ms. Guzman. But, ain’t much you or nobody can do for me. I messed up. Again. Why did I try to protect my Mama? She won’t even file charges against that SOB! I got my own problems, man. I’m tryin’ to get back on my feet. I’ve two babies and a girlfriend to support. (Becomes teary-eyed).

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sylvia: (Initially silent). Well. . . . I’m sorry to hear this, but to try to help you, I need to collect a little bit more information from you, okay? lloyd: (Sighing) Okay, what else you need to know?

In supervision, Sylvia discussed the dilemma that she believed she faced at this point in the interview: does she empathize with Lloyd (and use up the rest of the very little time she has left to collect the information she needed to prepare a report for the court) or redirect the conversation? Sylvia acknowledged feeling great compassion for Lloyd, but she believed she had to get the information from him that the office of the public defender needed. Although she felt “guilty” for doing so, she redirected Lloyd away from his feelings and back to the task of collecting information. Sylvia also expressed guilt that Lloyd seemed to “shut down” after his disclosure. We understand why Sylvia believed that she was in a no-win situation. She had yet to learn how to be both responsive and systematic at the same time. There are numerous ways Sylvia could have done this. Consider an alternative response: Wow, I can see why you might feel so defeated. I’m feeling torn here, Lloyd. It seems like it would be helpful to you to talk more about your feelings, just kind of let it all out. But I’m aware of the time, and we’re getting low on that. If circumstances were different, I’d want to help you work through and manage all that frustration. But I’m thinking the best way I can help you is to get all the information we need to present a positive report to the judge. What do you think?

Here, the worker empathizes with the client, engages in self-disclosure, and then redirects the conversation. The worker blends empathy with the more taskoriented aspects of her role. She recognizes the need to continue with the purpose of the interview, but she also acknowledges the client’s (and her own) feelings. As Sylvia discovered, when we try to continue with our purpose—in this case, the collection of information—without validating our clients’ feelings, it is unlikely that we will be either helpful or successful. The opposite, however, also would not be helpful. For the worker in this scenario to encourage the client to discuss in far greater detail his feelings (i.e., to use empathy instead of redirection) would have undermined her helpfulness. Lloyd might have felt understood, but it is likely that the worker would have left the meeting with an incomplete understanding of his situation, which could have worked against him in his court hearing. His coping abilities also could have been undermined; once he “pours his heart out” to the worker, the session ends, and he is left to cope with his feelings on his own.

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One final aspect of Sylvia’s work with Lloyd requires our attention. Sylvia acknowledged to her field instructor a desire to give him a hug to comfort him because he was so distraught. She did not do so, though, believing that it would be “inappropriate” for a worker and client to have any physical contact with one another. We agree, but not because physical contact is never advisable. Consistent with our discussion of physical contact in chapter 6, Sylvia and Lloyd had limited understanding of one another, and Lloyd could easily misinterpret any physical contact on her part. Sylvia was very comfortable with physical expressions of comfort and concern. However, in her interaction with Lloyd, she needed to consider how he might interpret such behavior. Instead of providing him comfort and conveying understanding, her behavior could have been distracting and misconstrued. Many potential clients have difficulty directly expressing feelings. This may reflect their fears about how we might react or what we might think. The feelings that will inevitably accompany their narrative may be conveyed nonverbally. Thus, for example, when a worker asks a middle school–age boy about being thrown out of his class, as he tells his story, he clenches his fists and raises his voice while reliving the experience. An empathic response, such as “Your teacher embarrassed you in front of your classmates” or “You seem to think that your teacher is always picking on you,” may help the youngster to continue his story and elicit his feelings in response. Clients may not know exactly what they are feeling, or they may have a mix of feelings. In these instances, we may need to put clients’ feelings into words. In the previous example, the school social worker could observe to the middle schooler, “You seem angry because of your teacher’s actions.” Social work students often express to us their reservations about engaging in this skill, worrying that they are “telling” their clients how to feel or “putting words” in their clients’ mouths. When we put clients’ feelings into words, we are not “making” them feel anything—rather, we are introducing possible affective reactions that might accompany their narratives. Two other empathy skills, verbalizing and acknowledging feelings, are useful when potential clients’ feelings are more apparent as they are telling their stories, and they encourage the clients to continue. For example, reaching for a specific feeling by saying, “How did your husband’s behavior with the children make you feel?” invites further discussion as the focus shifts from the situation to the reactions associated with it. In telling their life stories, clients often feel shame about events and situations in their lives, as previous examples in this chapter have shown. Legitimizing and universalizing clients’ thoughts, emotions, and reactions facilitate continued

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elaboration. Comments such as “Most people in such a situation would feel abandoned” or “Many people wrongfully blame themselves when such things happen” convey acceptance and invite further discussion. In the case of the adult survivor who holds himself responsible for his abuse even though his mother apparently knew what was happening, the following comment would normalize his experience and his reactions: “It makes sense that you, like other survivors, would rather think they were responsible for what happened rather than accept that their mom, who’s supposed to love and protect them, abandoned them.” We believe that when utilizing empathy skills, social workers are most helpful to their clients when they are one step ahead, rather than playing catch-up. In the example of the adult survivor of sexual abuse, he may not yet be ready to address his disappointment, anger, and feelings of abandonment associated with his mother’s unwillingness to protect him. However, it is unlikely that he will ever address a central aspect of his molestation unless he is helped to do so by the social worker. We have noted that potential clients often are ambivalent about seeing a social worker. Acknowledging and putting this ambivalence into words enhance the likelihood that they will accept our help. Readers will remember the challenges that the social worker faced in the scenario earlier in this chapter, when he attempted to enlist the help of the Dalton family in helping their son. We suggested that the worker was neither clear nor completely honest in explaining the offer of assistance to them. He also failed to address any reservations that they may have had. We suggest that a clear statement of the worker’s role and purpose in meeting with the Daltons, coupled with a statement such as the following, would have enhanced the likelihood of forming a partnership: Parents often question whether it is their fault that their child is having mental health problems. They worry that they will be blamed, that I will blame them. Any time a child has problems such as your son’s, this creates stress for everyone. It can’t be easy dealing with his outbursts. It must create much stress and tension. I want to help your son, but I also want to help you deal with him, since it has to be tough for you, too.

This skill is especially relevant when engaging mandated clients. We must be prepared to address the feelings they are likely to have about being forced to meet with us, which usually include anger and hostility, as we saw with Gwen’s interactions with George. These feelings and the resistance they engender are likely to be exacerbated when cultural and power differences exist. When clients are mandated to receive our assistance, putting into words their feelings about being forced to do something that they do not think they

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need or do not want is essential to engagement. In chapter 5, we introduced students to the solution-focused technique, coconstructing cooperation with mandated clients. Mandated clients may not share our—and others’—view of their problem, but they may be willing to agree that getting us out of their lives is something they would be willing to work on. When we use this technique, we are directly responding to and acknowledging clients’ ambivalence and encouraging them to make positive changes they might not otherwise consider. The mother who has lost custody of her children and now is mandated to attend drug treatment as a condition of her getting her children back may not think she needs help with her addiction, but she does want child welfare services out of her life. Professional Use of Self

We should expect that many clients will be uncomfortable sharing their troubles with a stranger. If the worker comes across as detached and impersonal, this increases anxiety and undermines potential clients’ willingness and ability to provide the needed information. Therefore, social workers must learn how to present themselves to clients in a way that is simultaneously genuine and professional. Perhaps more than any other set of skills, our ability to use ourselves—to be transparent—epitomizes the artistry of social work. Unless we are on total “automatic pilot,” we will always reveal something of ourselves in our work with clients. Both the knowledge and skill (the science) and the intuition and spontaneity (the art) of social work require that we learn when, where, and how to intentionally share our humanity with our clients. The worker’s ability to use oneself in a way that is helpful to clients is the subject of much discussion and debate. It also can be quite confusing to social work students. A core aspect of use of self is self-disclosure. Researchers and practitioners have distinguished two types of worker disclosures: “here and now” (or disclosures of immediacy) and “there and then” (or self-involving disclosures) (Knox & Hill, 2003). An example of a self-involving disclosure would be “I can understand your grief; my son died unexpectedly as well, and it was very tough for me for a long time” (said to a mother who has lost her young son). The worker shares her own experience of loss as a way of validating the client’s experience and conveying understanding. An example of a disclosure of immediacy would be “I am just so upset that that happened to you, that you were kicked out of school just for demanding you be able to use the boys’ bathroom” (said to a transgendered high school student). The worker shares his feelings about the unfairness of the client’s treatment—feelings that probably reflect those of the client.

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“Here and now” disclosures, which reflect the worker’s thoughts and feelings, are generally more helpful than “there and then” ones (Henretty & Levitt, 2010; Kelly & Rodriguez, 2007; Knox & Hill, 2003). While social workers and other professionals are reluctant to engage in self-disclosure, when they do, it is more likely to be a “there and then” disclosure (Hanson, 2005). The reasons for this are workers’ desire to reassure clients, normalize and validate their experiences, and convey understanding and acceptance (Hanson, 2005; Jeffrey & Austin, 2007). Examples of “there and then” disclosures drawn from our students’ work include: • “My parents divorced when I was in middle school, so I know how rough it can be” (said to a seventh grader whose parents’ contentious divorce was causing him to act out in school) • “It took me a long time to accept that I had a drug problem. I finally got clean when my parents threw me out of the house. That was when I hit rock bottom.” (said to a client with a substance abuse disorder who expresses fears that he will not be able to get or stay clean) • “My situation is a bit different, but my son also has learning disabilities, and it’s been tough dealing with the school sometimes” (said to parents who are frustrated that the school system is taking too long to respond to their request for testing for their learning-disabled daughter)

Additional case examples that illustrate disclosures of immediacy will appear in subsequent chapters, since research indicates that these worker behaviors are most helpful as the worker and client develop greater comfort with one another (Gelso et al., 2014). Based upon the available research, workers should consider three guidelines for effective use of self-disclosure in the beginning phase of work: 1. Giving basic biographical information, particularly about professional training, previous experience, and practice orientation, provides assurance to clients and enhances their willingness to engage in and satisfaction with a working relationship (Audet, 2011; Gibson, 2012). 2. “There and then” disclosures should be limited because they have the potential to be distracting and misunderstood (Pinto-Coelho, Hill, & Kivlighan, 2016). 3. The worker’s genuineness/transparency encourages and promotes client disclosures and engagement, particularly with mandated clients (Audet, 2011; Pinto-Coelho et al., 2016).

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Let us consider the practice applications of these three principles. We convey respect for our clients when we answer their questions or provide some information about ourselves. When a client asks, for example, “Have you ever been married?” a simple “Yes” or “No” may be all that is necessary to satisfy that curiosity. However, a question that seemingly requires a factual, straightforward response may reflect an underlying, more substantive concern. For example, an adult client who asks, “Are you an addict?” may really be asking, “Can you understand me and help me with the struggles I face trying to get sober?” Determining the meaning of questions that at first glance appear innocuous requires workers to use empathy skills and, as needed, put clients’ feelings into words. The agency context, workers’ comfort, and needs of clients also may determine whether certain questions should be answered. For example, if an adolescent asks, “Did you ever do drugs when you were my age?” she may be seeking a “yes” answer to justify her continued use of drugs. Rather than answering the teen’s question, the worker might say with a smile, “I think you want to know whether I ever used drugs because if I did, then you can say it’s okay for you to do it. So, there’s no way I’m answering that question!” Potential clients understandably—but incorrectly—assume that if their worker is similar in terms of personal characteristics and background, he or she will be better able to understand their concerns and be more helpful. However, our ability to be helpful does not derive from our similarities to clients. It results from using skills like anticipatory empathy, responding to clients’ verbal and nonverbal communication, clarifying role and purpose, and putting clients’ feelings into words. The following exchange occurred as Melanie, a student social worker, initiated her first session with a couple requesting bereavement counseling following the death of their child. The worker had explained her role and purpose and acknowledged how difficult the parents’ loss was (the child, age 10, had been run over by a car): melanie: I am sure this has been incredibly painful for you. Danny [the deceased child] died so suddenly and so tragically. Silence. melanie: I can only imagine how hard it must be to talk about Danny’s death. Silence. pam (mother): Can you really imagine? Do you have children? melanie: (Silent) Well . . . Doug, the father, rolls his eyes and sighs.

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pam: That’s what I thought. No children, and certainly no child that died! melanie: I’m sorry.

This scenario represents every student’s nightmare: they are asked about their own lives and must “confess” that they have not shared their clients’ experiences. As she discussed this exchange in class, Melanie acknowledged feeling “out of her depth” and, like her clients, questioned her ability to be helpful since she had not lost a child and did not have children. She had not yet realized that similarity to her clients was not the key to her helpfulness. Melanie was so focused on what she perceived as her inadequacies that she was unable to recognize her clients’ anger, which appeared to be directed at her but really reflected their anger at the unfair, unexpected, and terrible loss of a child. A more helpful response to Pam’s question would have been, “No, I don’t, and I’m wondering if what you are really asking is if I can possibly understand the depth of your pain and sadness, if I haven’t had children myself.” By putting the parents’ worries into words, the worker conveys that she can understand. The worker inviting clients to tell their story might follow a comment like this: “I can’t imagine what it’s like to lose the most important thing in your life—your child. It must be incredibly painful. How about you tell me what it’s been like for you?” Many of our students also worry about revealing their student status, fearing that their clients will not take them seriously. We suggest that the alternative—misrepresenting oneself—is unethical, as we have noted previously. But refusing to answer the question altogether is likely to alienate clients. While we are urging students to be honest when asked or when volunteering information about themselves, students, like their clients, have a right to privacy. The reason to withhold facts about ourselves should not be guided by “appropriateness,” but rather by our level of comfort and our assessment of the impact that a disclosure might have on a client. If, for whatever reason, the worker responds to a client’s request for information with “We’re here to talk about you, not me” or “It’s not appropriate to ask a question like that,” the client is likely to shut down and withhold information rather than sharing it. Consider the previous example of how a worker might answer an adolescent’s question about the worker’s use of drugs as an adolescent, as well as the following scenarios: • A social worker begins a session with a potential client who has been raped. The client asks the worker, “Have you ever been raped?” In fact, the worker had been raped as an adolescent. She believes that she has more or less dealt with it but

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prefers not to share her experience with the client. In response to the client’s question, then, she might say, “I understand why you might be asking this—you might wonder whether I can understand your experience. But whether I have or haven’t been raped, I still can’t know your experience. Please tell me what happened to you.” • A social worker works with adult survivors of sexual abuse, who often ask whether she would engage in various sexual behaviors such as oral or anal sex. Not only does the worker not wish to disclose this information due to its very personal nature, she also believes that it would be highly distracting and would not address the question that her clients are really asking, which is “Is it okay for me to do (or not to do) this?” and “Will you judge me?” Her reply might be, “I think I understand why you are asking about my sex life—you are trying to figure out what’s ‘normal’, what’s okay to do. But what works for me may not work for you. We have to help you figure out what feels right and comfortable for you.” If necessary, the worker also may need to say, “That’s a very personal question, and I don’t feel comfortable answering it, I’m sorry.” • A school social worker is leading a group for middle schoolers that focuses on decision-making and values clarification regarding sexual relationships. In one session, a member asks her, “When you were my age [15], were you having sex?” The worker replies, “Whoa, tough question!” and smiles. She then says, “I know you’d all like to hear that answer, but there’s no way I’m going down that road with you guys!” as she continues to smile. Then, more seriously, the worker says, “What I did as a teenager and what you guys do now is totally different. The times are different. And, what we have to do is to help you all figure out what’s right for you.”

Each scenario reflects instances of a worker not engaging in self-disclosure, but revealing their humanity. When we present ourselves as real—as transparent—in our earliest encounters with clients, we set the stage for successful engagement by creating a climate of comfort, safety, and trust. How we dress, what we say and how we say it, how we choose to decorate our office, our informal gestures, and the like all convey something about who we are as people. Our transparency will be both unintentional (the warmth of our smile and firmness of our handshake) and intentional (our clothing, the photos we choose to display in our office, if we have one). Purposeful use of self requires that we are sensitive to the impact that our transparency has on potential clients. In the case of the bereaved family, the social worker might consider stowing away photos of her own children, particularly when she first meets the family, since this might come across as insensitive. If the worker forgets to do this, or she does not believe it is necessary to do so,

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she will need to be sensitive to any indication from her clients that the presence of the photos is distressing. When one of the coauthors facilitates her group at a homeless shelter for families, she always dresses comfortably and very casually and wears minimal jewelry. The shelter clients are extremely disadvantaged and are almost always of color. Therefore, they are predisposed to assume that the coauthor, a white social worker of privilege, cannot understand their situation and will sit in judgment of them. While the way in which she dresses will not, in and of itself, eliminate residents’ doubts, it will make her more approachable and accessible to her clients. Transparency also may include gentle humor, which can relieve anxiety or embarrassment and ease suffering (Gitterman, 2003a). Humor that is selfdeprecating—when workers make fun of themselves—can be an effective way to reduce clients’ hesitancy and enhance their willingness to engage in a working relationship. Humor helps to equalize power and to normalize the helping process, but it must come naturally to the worker. Further, it should never be couched in sarcastic or hostile terms. Using Activity

Many clients have difficulty engaging with their workers, even when they have sought or are receptive to receiving help. Activities ranging from sports, board games and toys, arts and crafts, and books provide clients with a way to ease into their relationship with the workers because there is less emphasis on talking and more on doing. In chapter 8, we elaborate upon the benefits of activity; for some clients, it can be a means through which the work takes place. Examples of the use of activity in the beginning phase of work abound in our and our students’ work with clients: • A social worker in a residential treatment facility for adolescent boys conducts his first meeting with each of his individual clients as they play basketball or engage in some other sports activity. While they play basketball or throw a football around, the worker explains his role and purpose and invites the client to share his story and thoughts about being in the facility. • A social worker in an inpatient psychiatric facility is going to work with Daniel, an adult patient with a long history of mental illness. She finds him in the communal day room watching his favorite game show. She sits next to him, introduces herself, and explains that she will be his new social worker, She then asks him to explain to her what is going on in the show. The two then spends the next half-hour looking at and talking about it.

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• Deon, a 15-year-old black high school student, is required to work with the school social worker due to truancy and hostile behavior toward peers and teachers. In their first session, after the worker explains why Deon was referred to him and elicits his reactions to the mandate, the worker asks Deon what music he liked to listen to and suggests that he “teach this clueless white guy” something about it. They then listen to music on the worker’s smartphone while they continue to talk about how their work together could be helpful to Deon.

Establishing a Working Agreement

As social workers help potential clients describe the difficulties they are facing, they are also working on establishing a beginning mutual assessment of life stressors, how they are manifested, and the personal and environmental resources available for coping with them. The client and worker consider a stressor’s onset, duration, and intensity, what has been done about it so far, and the results. The worker and client then examine what each believes might be helpful, including hoped-for outcomes, priorities, respective tasks, and the next steps. Potential clients become actual clients when they and the social worker agree to work together within agency guidelines. Since the assessment may be tentative, the worker may need to reaffirm the agency’s function, the social work purpose, and how the work together will proceed. The description must be concise, explicit, and clear. After the potential client shares the relevant material, the worker summarizes the client’s concerns and life issues and asks for client feedback. As previous case examples reveal, this summary will include the workers’ own observations about what they have learned and observed. This provides an opportunity for clients to amplify messages not heard by the workers, clarify, correct the workers’ understanding, take stock, and continue the exploration if needed. Worker and client then examine what each believes might be helpful, including objectives, priorities, respective tasks, and next steps. Clients often present with numerous life stressors. They—and their worker— may struggle with where to start. Generally, the initial working agreement should tackle no more than three stressors at one time (Doel & Marsh, 2017). Decisions regarding where to start should reflect the clients’ sense of urgency and immediacy of need, as well as an assessment of which challenges may lead to a quick resolution and/or allow the worker and client to begin to alleviate other problems. Table 7.3 summarizes core skills for exploring and helping clients share their concerns.

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Table 7.3 Skills of Exploring and Helping Clients Share Their Concerns • Invite clients to identify their concerns. • Use minimal encouragers to invite elaboration. • Provide supportive statements. • Wait out silence. • Reach directly for the meaning of silence. • Invite facts. • Ask open-ended questions. • Repeat key phrases. • Rephrase and paraphrase questions. • Acknowledge and verbalize feelings. • Reach for specific feelings. • Legitimize and universalize feelings. • Use figures of speech and analogies. • The worker should share her or his own thoughts. • Use self-disclosure when appropriate. • Use timely humor when appropriate. • Summarize the discussion. • Explain the agency’s function and services. • Describe and explain the social work service and professional purpose.

Trauma-Informed Beginnings

Each of the skills that we have identified thus far, which promote engagement, the establishment of a working relationship, and mutual agreement, are essential in trauma-informed practice and its five principles: safety, trust, choice, collaboration, and empowerment. The unique needs of trauma survivors, coupled with the fact that the trauma itself may not be the presenting problem and may not even be known at the outset, require social workers to attend to three considerations in the beginning phase. First, the working relationship takes on special meaning when clients have trauma histories. It can be a source of safety and an opportunity for clients to begin to develop trust in themselves and others, but it also can reinforce mistrust and feelings of powerlessness. The worker must be honest regarding the reasons for, the nature of, and any mandates associated with the services they provide. The mandate to report suspected maltreatment of

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children often arises when clients have histories of childhood trauma. Consider the following case: A social work student, Kathleen, collected a social history from Sofia, a 33-year-old woman who had left her boyfriend due to domestic violence and sought housing in Kathleen’s shelter for domestic violence victims. The following exchange occurred when Kathleen asked a question about past history of abuse: kathleen: Were you ever the victim of physical or sexual abuse when you were a child? sofia: Yeah, my stepfather molested me when I was 7 years old. It only stopped when my mom kicked him out three years later. kathleen: I’m so very sorry to hear this, Sofia. This must have been very painful and scary for you. You were so young. I need to let you know that according to state law, I will need to report what you just told me to the appropriate department of social services. sofia: (crying and becoming angry) What? What are you talking about?! I don’t want to talk about that with anyone! I’m here because Carlos [the boyfriend] is beating the shit out of me, not because of something that happened 25 years ago!

Kathleen described her reluctance to ask Sofia about past child abuse; she was afraid that Sofia might say yes, and she would not know what to do or say. Ultimately, she handled the disclosure with sensitivity and empathy. However, her initial lack of openness regarding what would happen should Sofia acknowledge a history of sexual abuse undermined Sofia’s willingness and ability to trust and engage with her. In many settings, workers are required to ask questions that will require making a mandatory report, depending on the answers. The worker should preface these questions with their rationale in advance of asking them. Readers may question whether clients will respond honestly if they know that what they disclose will be reported. Research suggests that this fear generally is unwarranted (Dolgoff et al., 2012). Much more problematic is the mistrust that is likely to occur when a client is told after the fact what the worker must do with what has been shared. Clients may voluntarily disclose information that requires reporting. As we discussed in chapter 3, the social worker will need to explain why the disclosure must be reported, as well as tune in to and empathize with clients’ reactions and feelings about the mandate, as a way of minimizing the negative impact that the report might have on the working relationship. A second consideration associated with trauma-informed practice is the need to work within one’s role and to use empathy judiciously. Whether in

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response to a direct question or as a voluntary disclosure, clients’ revelations about past experiences with trauma may prompt us to empathize and encourage them to elaborate upon their experience. This may be problematic for two reasons. First, the invitation might undermine clients’ natural coping abilities, resulting in what is referred to as “flooding”: the client is overwhelmed with feelings (and sometimes memories) that undermine her or his ability to manage them. This is inconsistent with the trauma-informed principles of empowerment and control. Encouraging elaboration at this early point in the relationship also may be incompatible with our role. Kathleen’s empathic response to Sofia’s disclosure was consistent with her role and the purpose of her session. Through her response, the worker conveyed, “I hear you. I know this is painful,” but she did not ask for more detail. Kathleen was both responsive and systematic. Kathleen’s responsibility is to help Sofia find resources in the community to deal with her sexual abuse, since the shelter does not provide such assistance to its clients. Sofia’s trust and safety would be compromised if Kathleen offered help that she ultimately cannot provide (in this case, an invitation to focus on her feelings). A final consideration is associated with the worker’s affective reactions to clients’ disclosures of trauma. It can be extremely difficult to hear stories of clients’ pain and suffering. Trauma survivors’ narratives may be especially distressing and disconcerting to social workers when they occur in settings in which the focus is on current stressors in living. In many settings, a disclosure of past trauma may catch the worker off guard and lead to a comment or reaction that is ill timed and unhelpful. Let us turn to a different setting for a client’s disclosure of sexual abuse than Kathleen’s. The student, Leslie, was placed in the victim assistance program for domestic violence in the office of the state’s attorney. Leslie meets with clients only once, immediately preceding the court hearing in which the perpetrator is to be tried, and this meeting usually takes place right outside the courtroom. Her client unexpectedly disclosed a terrible history of sexual abuse as a child that included multiple perpetrators and sadistic violence. Leslie expressed sadness at what the client had experienced, gave the client a hug, and both ended up crying. When the case was called, the client was unable to testify because she was so emotionally distraught. Leslie was extremely upset at herself for being so “unprofessional.” Her reactions were perfectly understandable. Conveying her genuine distress to the client, unintended as it was, could have provided powerful reassurance. However, in this case, Leslie’s display of empathy weakened her client’s defenses at a time when she needed them the most. When we operate from a trauma-informed

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orientation, we learn to tune into our own feelings and reactions so that we use ourselves in ways that are helpful. We use supervision and the assistance of colleagues to manage our feelings so that they do not negatively affect our work and interfere in our personal lives. In chapter 12, we return to the need to take care of ourselves. We cannot be helpful to clients if we do not attend to our own needs. Beginnings with Families and Groups

There are some distinctive tasks and skills that are required when we are beginning with more than one client at a time. We must clarify our role and purpose, as well as the role and purpose of the group or family meeting. In social work practice with groups, members must understand that our responsibility is to connect them to and help them help one other. We must be able to explain directly, clearly, and in a nonjargonized way the concept of mutual aid. In social work practice with families, we clarify for the members in attendance that our role will be to help them come to agreement on the sources of stress in their lives and establish hopedfor outcomes on which members can commit to collaborate. In developing a common purpose with families and groups, the social worker directs and redirects member interactions to one another and helps them to express both common and different perceptions. The worker also solicits from members their reasons for, and their perception of, their stressors, and elicits feedback to ensure that the members themselves and the members and the worker are on the same page. Members are invited to build upon one another’s contributions, enhancing mutual involvement. The social worker helps group and family members to identify and focus on salient collective themes that underscore their commonalities, but also highlight differences. When working with families and groups, the worker helps the members establish ground rules that facilitate open communication and promote safety, mutual aid, and mutual understanding among group and family members. Expectations address participation: one person talks at a time, no one interrupts anyone else, and everyone is entitled to their opinion. Explicit rules that bar physical violence, verbal abuse, or threats also may need to be established. Additional rules that group members may decide on include attendance (for example, if a member can’t attend, the worker should be notified so that others don’t worry) and contact between members outside of the group and maintaining confidentiality (for example, what is discussed in the group stays in the group and group issues are discussed in the group, not outside of it). Readers must understand the purpose of ground rules they orient family and group members to the ways that they will work together to achieve their

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Table 7.4 Skills of Helping Group and Family Members Develop a Common Focus • Attend to each member’s verbal and nonverbal communication. • Direct and redirect member transactions to one another. • Invite members to build on one another’s contributions. • Identify and focus on salient collective themes. • Invite the expression of differences. • Reach for contradictory perceptions and opinions. • Invite participation of all members. • Establish protective ground rules.

common goals. When looked at this way, workers are less likely to feel the need to use group rules to discipline members who violate an expectation. A more helpful intervention would be to remind members why the expectation assists them in accomplishing their shared goals. We will return to engaging and working with families to address maladaptive dynamics in chapter 10, and with groups in chapter 11. The skills of helping family and group members develop a common focus are summarized in table 7.4. The following illustration comes from a group for substance abusers, all of whom are mandated to attend, typically due to being convicted of a misdemeanor or moving violation in which substance abuse was a contributing factor. Howard, the worker leading the group, assumes that the members are most likely in the precontemplation phase and therefore are not ready to accept the label of “alcoholic” or “drug addict.” The common belief among members is likely to be “I am not an alcoholic/drug addict . . . I don’t have to abstain from alcohol/drugs for the rest of my life.” Rather than challenge the members’ view of their problem (or lack thereof), the social worker works with it. howard: Thanks for coming out in such crummy weather [it had been snowing]. Before I ask you to introduce yourselves, let me just say that I get that most— maybe all—of you probably don’t want to be here. Members smirked and nodded in agreement. howard: When I met with each of you, I got the sense that some of you accepted that your drinking or drugging created problems for you—with your family, your employers, and, of course, now the law. But maybe you see it as they created problems for you. However you see it, you’re all in the same boat now— participate in the group or else face the consequences. What I’m hoping we can

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do in this group is help you all figure out what is going on with your using or drinking. And help you deal with the stress and pressure that it has created. Since you have had similar experiences, I thought you could offer each other support and help with the stress in your lives. I don’t have the answers, and I’m not going to preach to you about the “evils” of drinking and drugging. I’m here to help you learn from and support one another and help you get out of the jam you are in. Make sense? Most members nod. howard: So, how about we go around and introduce ourselves? Nick [sitting to Howard’s left], how about you start? nick: My name is Nick, and I want to make it clear that I am not an alcoholic, but I do drink a lot. I used to drink a lot of whiskey and ginger ale, and then I switched to wine. I used to buy two bottles of wine a day. It was costing me a lot of money. Now, I’m trying to drink less because I have big dental bills. I mostly drink only in the apartment. I don’t usually go to the bars to drink, but that one night—I was out with my buddies—and I got a DUI. Just bad luck! I drink a bottle of wine every night to help me sleep, sometimes a little more on weekends. I know I am not an alcoholic because I already cut down with no problem. My girlfriend is giving me a lot of shit about the DUI, and keeps telling me, “I told you so! I kept telling you were drinking too much!” ralph: I’m Ralph. I don’t consider myself an alcoholic either because I don’t really crave it. I do have problems when I drink too much. Whenever I start to drink, I drink too much, and something happens to me. I get into fights, or am attacked, or my wife gets crazy. I would like to stop drinking, but it’s hard, man. I got arrested for hitting some guy up the side of his head. He was giving my wife and me a bunch of shit so I punched him. It’s here or jail. jack: Hey, I’m Jack, and I work at the post office. My supervisor tells me I have a drug problem. I got hurt on the job a few years ago and had to take Oxy[codone], man. I still got pain so I still take the Oxy, but I got busted for trying to buy it from an undercover cop. My doc won’t give me it any more, man, but I still need it. I know I got a problem, but if my doc would prescribe me the Oxy, I’d be fine. But she says I don’t need it for the pain anymore. I don’t want to lose my job, and I sure as hell don’t want to go to jail. gary: Name’s Gary, and I suppose I am addicted. I drink on the spur of the moment, and I can’t seem to control it. When I can, I take Oxy or smoke or snort fentanyl. I guess I can’t kid myself anymore. I used to drive a cab at night, but I got a DUI, so now I’m not working. My boss said he’ll consider taking me back, but I gotta come to this group and I gotta get clean. I have lost some great jobs, and now my wife has moved out with the kids.

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dan: I’m Dan. I had my day with my son, and I took him to a party. I told my girlfriend [the son’s mother] I’d have him back to her by 5:00, but I lost track of time ’cuz I was partying, having fun. When I brought him back, she laid into me, yelling and screaming, telling me that’s it, she was reporting me to Social Services. She’d done it before, and I agreed to not get high when I had him. But it was just this one other time! Those fucking social workers investigated me again and sided with my wife, telling me that if I want to visit my son, I need to stop drinking and drugging. Right now, I can only see him with some social worker supervising me. howard: Thanks, guys, for sharing. It sounds like you aren’t convinced that there’s a problem with your using drugs or alcohol. But you got people in your lives who say you do, and that’s a problem. And you got the law—or social services— breathing down your necks. How about if we talk a bit more about that? About the stress you’re under? The members all begin talking at once. howard: Whoa, hold up! I’m glad to see you guys want to jump in the conversation, but if you’re going to help and support one another, we gotta have a rule that one person talks at a time, okay? No need to raise hands or anything like that. I’ll just remind you of this, making sure that everyone gets his turn, okay?

Here, Howard focuses on what members have in common at this early point in the group: the stress in their lives created by their substance use, as well as the requirement that they come to the group to avoid a more severe penalty. The members’ comments reflect the precontemplation phase, ascribing their stress to others’ response to their drug or alcohol use rather than the use itself. By focusing on members’ life stressors, Howard taps into the positive side of their ambivalence. Initially, the members’ only motivation may be to get out of the bind they are in and appease others who are putting pressure on them. However, this provides them with a place to start and a common purpose. He also establishes an important ground rule, which is that one person talks at a time. The members cannot help one another if they cannot hear what each other is saying. When group members are mandated, establishing a common focus may be relatively easy for the worker: members have in common their desire not to attend the group. This often is more difficult in family work, since members may have very different views of the sources of stress. For example, a significant life transition in families with children occurs when a child reaches adolescence. Tensions and conflict often surface, as the adolescent desires more independence and the parent or parents are reluctant to “let go.” From the adolescent’s perspective, the problem is his parents’ overprotective and controlling behavior.

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In contrast, his parents view the problem as his rebelliousness. In reality, all are experiencing stress, and the worker may need to point this out. A common pattern is for family members to place blame on one member: “If only she didn’t behave like she does, everything would be fine.” In this case, family members view their problem as residing solely in one member. The individual in this position is referred to as the identified patient (Satir & Banmen, 1991). Although not always intentional, targeting one individual allows members to deflect attention from other sources of stress that may exist in the family. Alternatively, members may view the source of stress as an issue, condition, or circumstance, without appreciating the role played by their interactions with one another. The Miller-Bland family—Brenda, age 35, and her wife, Ruth, age 38—have sought assistance due to tension that has surfaced in their marriage around the pressures associated with Brenda’s job. Ruth believes that Brenda works too many hours and is being taken advantage of. Brenda agrees that she has to put a great deal of time into her work, but she believes that it is necessary if she is to advance in her career. Both members assume that if Brenda’s job were different, the tension between them would disappear. In fact, as Brenda and Ruth describe the situation and the worker observes their interactions with one another, the worker believes that the source of the tension between them may actually stem from a different source: their disagreement regarding how to discipline Brenda’s 14-year-old daughter, Joelle. This dynamic, referred to as triangulation, allows the parents to focus (probably unintentionally) on Brenda’s work as a way of avoiding a more seriously contentious issue—disciplining Brenda’s daughter. In one final case illustration in this chapter, the worker attempts to help a family reach consensus on how their work together can be helpful. The Thompson-Johnson family—Katrina Thompson, 45; her mother, Mavis Johnson, 75; her stepfather, George Johnson, 77; and Thompson’s two children, Richard, 17, and Travis, 15—are going to be evicted from their apartment for nonpayment of rent. Mrs. Thompson, the sole breadwinner for the family, worries about how she can earn more money so that the family to afford another apartment, feels guilty that she has been unable to provide for her sons, and resents that she must take care of her mother and her mother’s husband. Her two sons are angry because they do not want to leave their friends and move to a new neighborhood. For their part, the Johnsons believe that they are a burden to the Thompson family and worry that their daughter will no longer let them live with her. As is often the case, this family initially came to the attention of the social worker because of the behavior of one member. The oldest son, Richard, has been truant from school and, when in attendance, has been combative and

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aggressive with classmates and teachers. The school social worker, Carey, met with the family in their apartment, explained her role and purpose, and asked each person in attendance to share their viewpoints on the sources of stress in the family. It is during this discussion that Carey learned about the eviction and how each member was experiencing it. The following exchange then occurred: carey: So, it seems like the one thing that everyone seems stressed about is the eviction, though each of you has your own concerns. Mrs. Thompson seems to feel guilty that she has to uproot the family again and worries about how to make ends meet. Richard and Travis are upset that they have to leave their friends again, but might also feel guilty that their mom is doing the best she can? Carey looks at the sons at this point. Richard nods slightly, while Travis looks uncomfortable. carey: And Mrs. Johnson and Mr. Johnson seem to be worried they’re going to be kicked out, and maybe they too are feeling guilty that they are a burden on Mrs. Thompson? Carey looks at the Johnsons, and both nod their heads. carey: So, is it possible that the guilt and the stress, and everyone worrying about the eviction, are just making it harder to deal with it? mrs. thompson: There’s so much on me! I’m trying, but nothing seems to be good enough. They (pointing at her sons) don’t do nothing to help me! Think the world owes them something! Life is hard! And them (pointing to her mother and her husband), they don’t do nothing either. I know she [her mother] can’t work, and George can’t either, but still, I got brothers and sisters who’s doing better than me. They won’t lift a fucking finger to help out! carey: So Mom is pretty angry with all this. But I’m wondering if the anger is more about just being overwhelmed? Carey looks at Thompson, who nods slightly. carey: And worried about her kids and her parents? And herself—how Mom is going to figure this all out? mrs. thompson: (Starts to cry). It ain’t easy. It’s all on me . . . carey: Richard, you look a bit uncomfortable, seeing your mom so upset? Richard nods. carey: I’m wondering if maybe Richard’s problems in school might be his way of expressing his upset? It’s like each of you is feeling alone, even though you all are really in the same boat: having to deal with another move and all that that means. The family members nod their agreement.

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carey: So maybe we can spend some time figuring out how you can support one another to make the eviction and move easier on everybody? And Mom, you and I can take some time to figure out how to get through this and hopefully keep it from happening again? Richard, you and I can also work on helping you keep it together in school so we’re not always on your butt about your behavior?

There are indications that Richard has taken on the role of the identified patient; all members of the family are stressed, but he has been the one who has expressed that stress in a way that led to negative attention in school and the label “troublemaker.” Carey identifies the common stressor that everyone is facing—eviction—and observes that each member is experiencing it in a different way, which undermines all the family members’ efforts to manage this transition. Carey also reframes Richard’s behavior in a way that connects him to his family. By doing this, she is setting the stage for members to work together to make the transition as easy as possible. She also will work with and support Thompson individually, who, as the family head, is the person most responsible for the decisions that need to be made. And Carey will work with Richard to develop ways to cope with his feelings about the stress at home so that he can be more successful at school. This case example reveals that decisions about with whom we will work— the whole family or specific subsystems in the family—will reflect our and family members’ understanding of the sources of stress and who needs to be involved in alleviating them. In many instances, such as this one, the practitioner will work with different members to accomplish different goals.

Helping Individuals, Families, and

EIGHT

Groups with Stressful Life Transitions and Traumatic Events

Helping people manage stressful life transitions and traumatic events requires distinctive knowledge and skills.

TRANSITIONAL PROCESSES AS LIFE STRESSORS Stressful Life Transitions

Across the life course, human beings must cope with numerous social transitions. We all must cope with stress associated with moving from one developmental phase to the next. Developmental transitions are affected by cultural factors. Adolescence, for example, is not recognized in all societies. In some cultures, puberty alone marks the entry into the rights and responsibilities of adulthood, with no intervening state. People also must deal with stress associated with entering new experiences and relationships and leaving familiar ones. Beginnings require a change in status and new role demands. When entering a new school, relationship, or job or having a child, changes in status often create some degree of stress even though

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these are positive events. Exits from desired social statuses imposed by divorce, unemployment, out-of-home placement of a child, or death of a spouse are usually more potent stressors than entry into new statuses because they often involve loss. Thwarted life transitions also can be extremely stressful. The diagnosis of infertility can be as painful as coping with the loss of a valued relationship. Children or parents may suffer terribly when their desire to be reunited following out-of-home placement are unmet. A high school student who is unable to pursue advanced education because of a lack of money also suffers from thwarted aspirations. Certain life transitions carry powerful societal and internalized stigma. Transitioning from a physically or mentally healthy person to a person with a diagnosis of mental illness, from a heterosexual to a homosexual or transgendered person, from a person with some difficulty with alcohol or pain to the status of becoming an alcoholic or drug addict, from an ambulatory person to a wheelchair-bound one carries significant adaptive burdens and challenges. The external judgments and personalized meanings and social identities attributed to these transitions substantially add to the level of stress. The timing of a life transition or event can affect individuals’ ability to manage it. When a new experience comes too early or too late in the life course, the potential for stress increases. For example, a young adolescent who becomes a parent or must assume parenting responsibilities for younger siblings, a young child who is not ready for day care, and a grandmother who must take on parenting tasks may experience intense stress because of the problematic timing. Stressful life transitions for individuals may result in profound and disruptive transitions for an entire family. A parent’s status as unemployed may result in eviction for all family members, or a parent’s mental or physical illness may result in other members—including children— having to step in to fulfill the responsibilities and roles previously held by the incapacitated member. Life transitions that are considered more normative and expected also may create stress for families. A remarriage often results in the blending of two families—a transition that requires all parties to adapt to a new set of norms and role expectations. The birth of a child also requires adaptations on the part of family members, while the military deployment of a family member requires other members of the family to fill the void created by this absence. Like individuals, families must cope with difficult and often unexpected life transitions, such as becoming homeless, a natural disaster like a hurricane or earthquake, community violence, and murder of a family member.

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Some people have the additional burden of simultaneously dealing with developmental changes, social life transitions, and traumatic events. For example, Louise, a 13-year-old Jamaican girl, was admitted to the hospital for surgical correction of scoliosis (curvature of the spine). Since the operation, she has been in a full-body cast, which keeps her flat on her back. After the cast is removed, she will be in traction, and following discharge, she will require weeks of recuperation at home. The head nurse referred Louise to the hospital’s social work department because of crying fits, tantrums, and uncooperative behavior. The worker learned the following from Louise and her family: When Louise was five months old, her parents left Jamaica for England and better economic conditions, leaving her with her grandmother in Jamaica. Many years passed, and Louise’s parents had seven more children. Louise knew of her parents and siblings in England but had no contact with them. The only mother Louise knew was her grandmother, and her first nine years were apparently happy and stable. One year ago, her grandmother became ill and could no longer care for her. Louise was sent to the United States to live with one of her aunts, who was married with children of her own. The aunt accepted full responsibility for the care and financial support of Louise. The aunt said that Louise adapted well to her new living circumstances. She made friends and was cooperative and helpful around the house. Although bright, Louise’s aunt described Louise as “lazy” about studying. This resulted in her having to repeat the fifth grade. She is now in the sixth grade. Recently, her grandmother died, and the aunt said Louise took the loss very hard. Louise’s medical problem was only recently recognized. She started walking awkwardly a year ago and began complaining of back pain. When her pain became worse, her aunt brought Louise to the hospital, and x-ray and MRI tests revealed the scoliosis Her aunt told Louise’s mother about the surgery, and she flew to the United States. The visit was extremely upsetting to Louise. In front of the aunt and Louise, her mother complained that Louise was “spoiled” and talked of taking Louise back to England, but she stopped short of taking any action. The mother visited Louise three more times, one of which went badly, when she told Louise how homesick she was and how she wanted to go back to England. Louise told her mother that if she wanted to go, she could. Louise began crying uncontrollably and having violent verbal outbursts after her mother left for England.

This early adolescent has endured many losses and challenging life transitions. She faced the pressing tasks of adapting to a new environment; a new family; a new school; a different climate, culture, and lifestyle; the loss of her

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beloved grandmother; rejection by her own mother; the medical trauma of hospitalization, pain, and surgery; and the prospect of a long convalescence. All transitions must be understood within a cultural and developmental context. Louise’s roots in Jamaican and West Indian culture lead her to place great value upon family, including extended family. Her aunt’s willingness to take in and raise Louise is evidence of the value that kinship ties have in their lives. However, Louise’s extended family has been in the United States for many years, which has led to diminished importance of their Jamaican heritage in their everyday lives. Louise, on the other hand, remains very connected to her Jamaican roots, which makes it more difficult for her to adapt to her new home and surroundings, and manage the grief associated with the death of her grandmother and loss—once again—of her mother. The hospital social worker needs to be sensitive to Louise’s cultural identity as Jamaican—rather than African American—and how this affects her ability to navigate the many significant transitions she is facing. This includes Louise’s ability to manage the developmental tasks associated with adolescence: developing a sense of identity, connecting with peers, and the like.

SOCIAL WORK FUNCTION, MODALITIES, METHODS, AND SKILLS The Worker and Stressful Life Transitions and Traumatic Events

When clients experience life stressors that arise from difficult developmental and social transitions and traumatic life events, the social worker helps them effectively cope with the biological, cognitive, emotional, behavioral, and social demands posed by the life issue within a particular environment and cultural context. The social worker also helps clients develop or strengthen their adaptive capacities and promotes responsiveness in clients’ social environment. The worker’s interventions are designed to promote resilience and adversarial growth. Professional Methods and Skills

Helping individuals, families, and groups cope with painful life transitions and traumatic events requires a repertoire of professional modalities, methods, and skills. By enabling, exploring, mobilizing, guiding, and facilitating, the social worker supports and strengthens people’s adaptive capacities and problem-solving abilities. A key premise of life-modeled practice is that how we think, how we feel, and how we act are interconnected and interdependent. Under ideal circumstances,

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individuals grow up in a loving and supportive environment and develop feelings of positive esteem and worth and beliefs (thoughts) about themselves and others characterized by trust and confidence. These thoughts and feelings then lead to relationships with others (actions) that reinforce positive self-worth and trust and confidence. For many of our clients, however, the thinking-feeling-doing connection results in a self-reinforcing negative cycle.1 For example, Stephanie was sexually abused as a child. She developed feelings of self-loathing and shame and the thought that she was responsible for the abuse and all she was good for was sex. As an adult, she sought assistance from the social worker because of her loneliness and the fact that “men treat her like crap.” Stephanie typically met men at bars and “hooked up” with them for a one-time sexual encounter. Her actions and the response that she got from men reinforced her feelings of shame and belief in her worthlessness. Our job is to help clients break this vicious cycle. Sometimes that will be enough to help clients like Stephanie work through their feelings and examine and challenge those thoughts that undermine their ability to successfully navigate life stressors. In many cases, we will need to help clients do things differently. Clients may learn to manage their feelings and develop insight into why they feel and think as they do, but this may not be enough for them to act differently. All of us become accustomed to behaving in a certain way, even if that behavior is unsatisfactory, counterproductive, or unfulfilling. Therefore, clients often will need our help in giving up old ways of behaving (and thinking and feeling) for new ones. In this chapter, we focus on the practice methods and skills that help clients to process thoughts and feelings about their stressful life transitions and past traumatic events. In chapter 9, we discuss the skills that assist clients in doing things differently to develop greater competence in their transactions with their social and physical environments, as well as the ability to directly influence their environment so that it is more responsive to their needs. The examples in this and the next chapter illustrate the interdependence of life transition and environmental stressors. Therefore, in our work, the focus can, and usually does, shift back and forth between clients and the social environments within which they live and upon which they depend. Our professional task is to be responsive to what clients are asking for help with at any particular moment in time. We separate these chapters only to clarify the presentation and to help readers to develop a clear and flexible focus in their practice.

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Enabling Skills

In previous chapters, we have discussed empathy skills, which expressly focus on clients’ feelings. The first set of skills presented in this chapter are those that help clients both think and feel differently about their situations. These build upon the empathy skills discussed previously and are summarized in Table 8.1. Enabling skills convey to clients, “I’m with you and want to help you with your concerns.” Helping clients express their concerns requires us to encourage with minimal responses; wait out silences; reach for facts; verbalize feelings; legitimize and universalize thoughts, reactions, and feelings; emphasize and highlight specific cues; rephrase concerns; use figures of speech and, occasionally, humor; and share one’s thoughts and feelings as appropriate. Exploring and Clarifying Skills

This set of skills provides focus and direction to the work. Some clients confide in and explore their life stressors with relative ease, others ramble on without focus or direction, and still others remain silent. In helping clients to unburden and explore their concerns and feelings, the social worker’s tasks are to help the person explore the objective facts and subjective reality about the life-transitional stressor or traumatic event.

Table 8.1 Enabling Skills • Use minimal responses to encourage clients to talk. • Wait out a silence if it occurs. • Reach for facts. • Verbalize feelings. • Legitimize and universalize thoughts, reactions, and feelings. • Reach for specific feelings. • Highlight specific cues. • Rephrase concerns expressed by the client. • Use metaphors, analogies, and euphemisms. • Use humor as appropriate. • Summarize the client’s concerns. • The worker can share thoughts and feelings as appropriate.

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The worker assumes the initiative in stepping out in front of the client to deepen their professional relationship and further the client’s efforts to manage life stressors. These interactions should be responsive to clients’ signals that they are ready to explore and clarify, rather than reflecting the worker’s impatience or need to be in control. Our job is to follow and build upon clients’ cues—even when they themselves may not be fully aware of them—rather than the reverse. The 12 interdependent and overlapping skills discussed next assist with these tasks. Developing focus and direction. The social worker explores and clarifies clients’ communication, conveying, “I need your help in understanding your situation better.” By developing a clear and mutual focus in the work, the client and social worker minimize the emergence of competing or overlapping concerns. Focus and attention are associated with the achievement of agreed-upon goals. Specifying concerns and clarifying communication. People often express their concerns in vague phrases such as “My child is out of control” (spoken by a mom who is being investigated by child protective services) or “I just had a few drinks” (reported by a client who has been ordered to attend a substance abuse program by a court following a charge of driving under the influence). A general term may obscure an important life story and have different meanings to clients and social workers. Abstractions such as “out of control” and “a few” require clarification: “In what way is he out of control?” “Can you give me an example of his being out of control?” “How many is a few?” Specifying what clients mean improves clarity in communication. Asking clients to be more specific and clarify their communication is also necessary when their language includes colloquialisms, slang, and other words and phrases with which the worker is unfamiliar. Members of a shelter group run by one of the coauthors were expressing anger at another member, whom they described as “bougie.” While their anger was clear to the coauthor, the reason for it was not. She needed to ask for help in understanding the word “bougie” (which means “uppity,” or thinking one is better than others). Once the coauthor understood what members were saying, she could help them—and the new member—see how her dress and demeanor served as a defense against the reality of her situation. Despite her appearance—she dressed in expensive clothes, wore stylish jewelry, and was carefully made-up—the new member was in the same boat as the others in the group. She was a college graduate who had a good job, but who developed an addiction to cocaine. As a result, she lost everything, including her friends, family, and home. Students often express concerns about asking clients to explain themselves or the words that they use. They do not want to appear stupid or clueless. However,

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we cannot be helpful if we do not understand what our clients are telling us. The “out of control” situation in which the child is talking back to his mother requires a very different intervention than if he is hitting her. The individual who had eight beers and two shots of alcohol prior to driving a vehicle may be at a different stage of change than one who had three glasses of wine. Sharing puzzlement. Social workers may convey confusion as a way of prompting clients to think more carefully about their thoughts and feelings: “I am unclear about what you’re really thinking. On the one hand, you’re saying that you’re going to get your GED, but on the other hand, you’re telling me that you’re ‘stupid’ and might as well just give up on school. Can you help me understand?” (said to a youthful offender who has been court-ordered to obtain his general equivalency degree). Asking for help in understanding can clear up contradictions in behavior and ideas for clients as well as workers. Reaching for the meaning of experiences. People attribute different meanings to life experiences. The worker explores with clients their unique interpretations of their experiences. By reaching for the meaning of experiences, the social worker explores belief and value systems that influence behavior. For example, the mom being investigated by child protective services for responding with harsh discipline to her 16-year-old son’s “disrespectful” behavior learned as a child that such behavior was strictly forbidden. She comes from a country— Nigeria—whose culture requires that children never question their parents’ authority and always obey them. In another example, a family is struggling with the death of a member, the youngest child. The worker will need to invite each member of the family—each parent, the grandmother, and two siblings—to share what the loss means to them. The parents’ grief is likely to include feelings of guilt that they were unable to protect their child, while the siblings’ grief may reflect guilt that they survived and their brother did not. Exploring ambivalence. In chapter 7, we described the ambivalence that many clients experience about seeking out and accepting our offers of help. Clients may continue to struggle with ambivalence about the steps they need to take to deal with the stress once they are engaged in the work. In exploring ambivalence, the worker may examine the duality of conscious feelings: “You seem to accept that you have a problem with alcohol, but yet you seem reluctant to take the next step.” Clients may be aware of one aspect of their mixed feelings, but not another. Thus, gentle questions or comments may help clients see the full extent of their confusion. The worker in this example might need to continue by saying, “People often say that admitting you have a problem is the hardest part of recovery. But sometimes admitting the problem leads to the question,

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‘Now what?’ and that can be scary. Is that part of what is making it so hard to take the next step?” Exploring ambivalence is a form of empathy where the social worker reaches for the feelings behind a client’s behavior. Ambivalence, which often is unconscious, can exert a powerful influence on behavior without the clients’ knowledge. In these cases, the worker’s use of empathy may involve putting clients’ feelings into words—feelings of which they themselves may not yet be aware. In a group for victims of domestic violence, the worker observed that the members have been focusing on what they did to bring on the abusive behavior. She comments, “I noticed how much time you all have been spending on figuring out what you did to cause your partner to abuse you. Perhaps you’re thinking that if you could figure that out, you could make him stop. But I’m wondering if what’s really going on is that you want—maybe even need—to feel like you can control the situation. Otherwise, you’d have to accept the fact that you can’t change him; you can’t make him stop abusing you. Which means you’d have to accept that stopping the abuse means taking steps that are pretty scary, like leaving him.” Identifying discrepant messages. Mixed thoughts and feelings often are communicated through contradictory messages. To explore the extent and depth of life-transitional concerns, discrepancies between verbal and nonverbal behavior are identified and clarified: “You say it doesn’t bother you, but I notice you are clenching your fists, which suggests to me that maybe you are upset?” “I am confused. You say how angry you are at your boyfriend’s coming home at 2 a.m., but then you turn around and have sex with him.” “On the one hand, you say that you are concerned about how your son is doing in school, but on the other, you missed the two appointments that we scheduled to talk about his academic performance and behavior in the classroom.” Pursuing suppressed feelings. One way that individuals manage difficult feelings and experiences is to shut down emotionally. Their feelings are divorced from their experiences. This is variously referred to as intellectualization, repression, denial, and dissociation. Clients may be unaware of their feelings, even though their affective reactions continue to influence their thoughts and actions. Workers, then, may be required to help clients uncover their buried feelings. This empathy skill is a variation on putting clients’ feelings into words. For example, a student worker is helping Jared, a 20-year-old man, find a place to live, obtain his GED, develop a résumé, and begin to look for work. Since he was 10 years old, Jared has been in four foster homes and currently resides in a group home. His original removal was prompted by sexual abuse by his mother’s boyfriends and her drug addiction. Jared was physically abused in three of the foster homes and removed from another due to the

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drug addiction of the foster father. He has done well at the group home but is “aging out” of foster care. The worker noted to his field instructor how “uninterested” and “apathetic” Jared is when they meet for their individual sessions. His field instructor asks him to tune in to how Jared might be feeling, both about his leaving the group home and about his experiences in foster care. Based upon this reflection, in his next individual session with Jared, the worker observes, “I’ve noticed how emotionless you have seemed. You’re facing so much; you’re leaving us and moving on in life. And you also probably have lots of feelings about all that you have experienced in your life—being taken from your mom, being abused, being shuttled from one bad foster home to another. All this must take its toll on a guy. I’m thinking that perhaps we need to start to talk about all that pain from the past and fears about the future?” The student’s observations reflect the thinking-feeling-doing connection. Jared has experienced much trauma in his young life and has never had an opportunity to discuss any of it. He has managed to get this far by shutting off his feelings. Now that he is facing a very stressful life transition—becoming independent without adequate preparation to do so—the worker must try to help him face the pain, anger, hurt, and self-blame that resulted from his experiences in foster care and are likely to undermine his efforts to successfully transition to independent living. Pointing out patterns. In discussing stressors, clients may focus on details or behaviors without recognizing that they reflect an underlying theme. This is consistent with the familiar adage that sometimes we “can’t see the forest for the trees.” When clients recognize a pattern that explains what they have understood as isolated incidents, they are better able to address and manage them. The worker observes to a single parent who describes a number of struggles, “You’ve talked a lot about your boss and how she treats you unfairly, and you say your kids walk all over you. And now you’re saying your parents won’t help you out with childcare. It seems like there’s an underlying pattern here: that you feel unappreciated in your most significant relationships.” The client may need help developing strategies to manage stress and learn to advocate for herself, since the lack of these two capacities may underlie each of her individual complaints. In a group for rape survivors, the social worker observes to members, “You’ve been talking about problems in your relationships: Sandy, you’re having trouble trusting your husband; Sylvia, you’ve talked about how you’ve distanced yourself from your boyfriend; and Leila, you just mentioned that you’re wondering whether your fiancé is really the one for you. You also have been talking about how you’ve become self-conscious, withdrawing from friends and family. It’s possible that these behaviors, which seem different on the surface, actually reflect your

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underlying fear, or worry, that something you did caused what happened. It’s not so much about trusting others—it’s about whether you can trust yourselves.” Offering a hypothesis. As the previous examples indicate, a hypothesis provides a new frame of reference for clients to consider, such as, “Do you think it is possible that a lot of your hurt and anger with your father is being directed at your son?” or “I wonder if your husband gains control over you through his silence?” Skilled, tentative questions offer clients a different way of viewing their situations and may prompt them to reconsider their experiences and viewpoints from a more accurate and useful perspective. The timing of such offerings is important, as is the worker’s ability to tune in to clients’ reactions to them. When an interpretation is offered too early, not only might it be inaccurate, but clients also may have not developed sufficient trust in and comfort with the worker to be able to refute or question the worker’s observation. Even when it is accurate, clients may not be ready to accept the worker’s perspective. We have noted previously that the worker must be with the client at the moment and, when appropriate, also several paces ahead— providing clients with a new way of viewing their situation rather than playing catch-up—even if they are not quite ready to consider what the worker is saying. A worker, Bryce, is seeing a father and son, Mr. Michaels and Joshua, mandated to receive counseling due to the son’s recent involvement in criminal activity. Bryce initially assumed that the focus of their work would be on Joshua’s behavior, consistent with the court mandate. In the first session with father and son, though, Bryce learned that Mrs. Michaels recently passed away. He also discovered that the mother had been the primary disciplinarian in the family. Her death was not only a significant loss for both father and son, but it also left a void in Joshua’s parenting. This void was compounded by the amount of time that Mr. Michaels was required to spend at work, as well as his grief, which led him to withdraw from everything, including his son. Bryce hypothesized to father and son, “I’m thinking that perhaps part of what’s going on here is that you both are grieving the death of your mom and wife, but may be doing it in different ways. Dad, your sadness may have made it hard to step in and provide to Josh the structure he needs. And perhaps, Josh, maybe you see your dad’s not being around for you as a sign that he’s left you to grieve all by yourself? That you are all alone? In reality, both of you are struggling with the same thing: you miss your mom, Josh; you miss your wife, Mr. Michaels.” In addition to providing a hypothesis, Bryce provides the father and son with a different way of looking at their behavior. As this conversation continued, Joshua revealed that he assumed his father’s withdrawal meant that he no longer loved him or cared about him. At precisely the time when the son needed his

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father’s presence in his life, the father—due to his own grief—was withdrawn. Father and son gradually came to understand that the father’s withdrawal, coupled with his grief, contributed to Josh’s acting-out behavior. Inviting feedback. Inviting clients’ reactions should follow the worker’s interpretations and directive interventions: “What’s your reaction to what I suggested?” “I’m wondering what your thoughts are about what I just said?” Clients directly respond whether the hypothesis or interpretation is helpful or unhelpful. More likely, however, they will provide feedback more indirectly: “I guess you’re right,” or “Yes, but . . .” The worker reaches for hesitation, lack of clarity, or negative reactions. Even if the interpretation is perceived as unhelpful, the client’s feedback stimulates further work. Without client feedback, the worker may sound smart or be insightful, but the work is not deepened. Providing behavioral feedback. People may be unaware of how others perceive them. When we share our reactions to clients, we provide valuable feedback—feedback that they are unlikely to get elsewhere. When offered out of caring and concern, not because of frustration or anger, such feedback is more likely to be accepted. It is important that the worker offer reactions directly and in a neutral manner: “When you answer only ‘yes’ or ‘no’ to my questions, I feel frustrated because it is hard for me to understand where you are coming from, and I really want to understand.” This feedback is presented in concrete, behavioral terms and expressed calmly, in a caring manner. The worker’s comment also reflects transparency and a “here and now” disclosure about what is going on for him in the moment, as discussed in chapter 7. In a session with a family in counseling due to the son’s substance abuse, the worker observes to the parents, “I think that Joe [the son] might perceive your reactions and comments to mean that you see his addiction as a sign of weakness—that if he just puts his mind to it, he should be able to swear off alcohol.” The worker’s comment was prompted by his assessment that while the parents have maintained that they support and understand their son and want to help him achieve sobriety, indirectly they seem to be sitting in judgment of him. Even though this message may be subtle, Joe will inevitably sense it. Since he is unlikely to confront his parents directly, it is the worker who must do so, as the guilt that Joe is likely to experience from doing so himself will undermine his efforts to help him become clean. Another social work intern provides feedback about a client’s demeanor toward her. The setting is a correctional facility for women, and the worker is assigned to help Marvelle prepare for her parole hearing. Because of her good behavior in prison, Marvelle has an opportunity for early release. They have been discussing where Marvelle will live, as well as how she will stay clean (since the

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reason for her incarceration was writing bad checks to support her addiction) and how to present herself to the parole board. The following exchange then occurred: worker: I know you want early release, right? Marvelle nods her head in agreement. worker: I have to tell you, the way you have interacted with me in our last couple of sessions sends me a different message. If I didn’t know better, I’d think you couldn’t care less about being released. There’s sort of this “Fuck you” attitude. Doesn’t bother me, because I know how stressed you are, but it sure isn’t going to go over well with the board.

Marvelle is facing a significant life transition requiring that she and the worker consider the impact that the environment—the parole board—could have on her ability to leave prison early. In chapter 9, we discuss the fact that social workers and clients are often required to simultaneously address stressors associated with life transitions and clients’ social environment. Inviting self-reflection. Self-reflection and self-discovery have more profound and lasting outcomes than solely providing interpretation. When a client grasps the relationship between current and past experiences, the realization is more likely to be “owned” and transferred to other situations and experiences. Encouraging clients to reflect on self-defeating behaviors might be initiated by tentative questions such as, “Do you sense any similarities among the last three men you have dated?” Such questions enable clients to develop insights into their life experiences. By encouraging a client to self-reflect, dependence on the worker decreases and self-direction and self-regulation increase. Clients will vary in their ability to achieve and benefit from insight. We must be prepared to offer our own insights for consideration when clients have difficulty doing this on their own. For example, if the worker’s question to the client about men she has dated is met with confusion or silence, she may have to go further and suggest, “It seems like the last three men you have dated have all been controlling and emotionally abusive.” The worker might have to go even further: “How about if we spend some time talking about how come you seem to choose the same type of guy over and over?” Continuing with a previous example, after the worker’s feedback about Marvelle’s demeanor, the following exchange occurred: marvelle: (looking confused) I don’t understand what you’re telling me. I’m trying hard! I want to get out of here! worker: I know that you do, Marvelle, I really do. What I’m saying is that the parole board might see your behavior differently. Can I give you an example or two?

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Marvelle nods. worker: Well, for example, most of the time, you don’t look at me when we talk, and sometimes you look sort of bored, though I know you’re not. You roll your eyes a lot, and some people might see that as a sign that you don’t care, though, like I said, I know that that’s not true. I know that you want out of here, but can you see why the board might conclude otherwise if you acted that way with them? Marvelle nods. worker: So, how about we talk about why you might be sending the wrong message? Why you might come across with an “attitude”? marvelle: I really don’t know! I want to come across well to the board! worker: I know you do, but is it possible that you worry—or even assume—that you’ll be turned down for early release, so you don’t want to get your hopes up? Maybe that’s why you might look sort of like you don’t care? marvelle: (silent for a moment) Well, yeah, I don’t want to get my hopes up. So much bad shit has gone on with me that it’s hard to think this could go right. worker: Okay, so I’m thinking that we can help you with those feelings and prepare you for the hearing. That make sense?

The worker helped Marvelle see that her pessimism led to nonverbal behaviors that could work against her in the parole hearing. We return to this case in the next chapter, when we discuss how workers assist clients in interacting with their environment more effectively. Table 8.2 summarizes exploring and clarifying skills that enhance clients’ understanding of themselves, others, and their situations.

Table 8.2 Exploring and Clarifying Skills • Develop focus and direction. • Specify concerns and clarify communication. • Share puzzlement. • Reach for the meaning of experiences. • Explore ambivalence. • Identify discrepant messages. • Pursue suppressed feelings. • Point out patterns. • Offer hypotheses. • Invite feedback. • Offer behavioral feedback. • Invite self-reflection.

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Motivating Skills

The social worker often must reinforce and strengthen clients’ motivation and ability to address life transitions and manage associated stress. For some clients, our support, caring, and interest, as well as the assistance that we provide in exploring their concerns, are sufficient to initiate their problem-solving abilities. Many other clients, however, require more help with mobilizing their personal strengths and resources. The following skills assist clients in this regard. Identifying strengths. People who seek out (or accept the offer of) professional help often feel inadequate and insecure. The act of seeking or being offered help can reinforce clients’ feelings of inadequacy. Self-doubt and preoccupation with life stressors and limitations can be immobilizing. The worker breaks through this barricade by helping clients identify their strengths. The worker can simply ask this question directly: “What are your strengths?.” In many instances, clients will be unable to answer this question. In chapter 5, we introduced readers to solution-focused questions that elicit from clients their strengths and adaptive capacities. Asking about exceptions questions require clients to identify times when they managed life stressors more effectively. Coping questions assist clients in identifying how they are managing, despite how overwhelmed they are, and this type of question is helpful when asking about exceptions would be too difficult for clients to answer. Both questions convey to clients that they do have strengths, even if they are not yet aware of them. The underlying assumption is that clients are the experts about their lives. With the worker’s help, clients identify strengths that they have already used, which they can employ more intentionally to tackle the challenges that they face in the present and future. We also cautioned in that discussion that social workers need to be persistent in eliciting answers to solution-focused questions because clients typically have not viewed their past attempts at coping through a strengths-based lens. Therefore, there may be times when workers will have to be persistent in eliciting strengths: “Raising three children as a single parent and working full time takes so much energy, determination, and skill; let’s look at all the things you do to manage so effectively.” Offering reassurance and hope. At times, realistic reassurance provides important support: “The doctor told me you are undergoing a simple surgery, and she is confident there is absolutely nothing to worry about. But any time we have to ‘go under the knife’, we still might have some concerns. So how about if

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I try to answer your nonmedical questions, and we work on having your doctor answer your medical ones?” Without hope that things can improve, clients’ despair can undermine their motivation. “Why should I try, since nothing is going to change anyway?” is a common sentiment among many clients. The social worker offers hope by conveying to clients that that their work together will make things better. Hope is conveyed subtly but powerfully by the way that we frame our questions to clients. “Tell me about a time when you were managing your stress better” takes a far more optimistic tone than “Was there ever a time when you were managing your stress better?” The first question assumes that there was a time when the client was more successfully managing life, consistent with a solution-focused orientation. It is the worker and client’s job to identify what contributed to that success. Students often are tempted to use these mobilizing skills because they want to “make clients feel better.” While we understand this desire, superficial compliments and praise are ultimately unhelpful. Clients are likely to recognize the inauthenticity of the comment (and extrapolate that to the worker making it). The value of reassuring, identifying strengths, and offering hope is to enhance motivation and provide clients with the tools they need to successfully manage life transitions in the present and future. But it has to be genuine and real. One of our students responded to her clients’ distress over the loss of her home and property (as well as a beloved pet) due to a fire by saying: “Just remember, you all [a mother and her three children] got out alive. You can replace your furniture and all the other furnishings, even your cat, but you can’t replace one another.” The student reported that her comment was met with silence, which led her to realize that her comment allayed her discomfort, rather than her clients’. The comment reflected her desire to make the family members feel better, but it actually was unhelpful, since they were only beginning to grasp the extent of their loss and beginning to grieve. At this early point, the worker’s comment is likely to be experienced as insensitive and lacking in empathy. The interpretation of the fire offered by the worker is one that she can help family members achieve over time; but this can occur only if the worker conveys her understanding of the client’s initial feelings of despair, hopelessness, and sadness. Table 8.3 summarizes skills that enhance client motivation. Table 8.3 Motivating Skills • Identify strengths. • Offer reassurance and hope. • Avoid artificial reassurance and false hope.

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Guiding Skills

Many clients are unable to manage their feelings and resolve life stressors because they lack necessary information or are hampered by misinformation. Others have difficulty because they do not recognize their maladaptive, often self-defeating patterns. Clients also may be so overwhelmed by life events that they are unable to manage their feelings and mobilize their problem-solving abilities, even with the worker’s assistance. In addition to providing needed support and using empathy skills, the worker employs the following guiding skills to encourage clients’ inherent coping abilities and enhance their understanding of their situation and themselves. Providing relevant information. Information about clients’ concerns principally flows from them to social workers. However, clients also need and expect to get relevant information from workers. For example, information about the common phases of bereavement and community resources is an essential tool for effective coping with loss. In a group for victims of intimate partner violence, members need to understand the cycle of violence that keeps them in the relationship: they are beaten, the perpetrator apologizes and assures them that it will never happen again, which leads them to stay; and then the cycle begins again. Knowledge is empowering and contributes to clients’ abilities to manage and overcome life stressors. Correcting misinformation: Misinformation about physical, emotional, and social functioning can make an already stressful situation even more stressful or lead to even more stressful life transitions. For example, in a group for middle schoolers that focuses on sex and sexuality, members are asked to anonymously write down their questions. The worker then addresses each question in the group session. One question is, “Is it true that a girl can’t get pregnant the first time she has sex?” and the worker tells members that is not true: a girl can get pregnant the first time she has intercourse (a fact that contributes to a significant number of teen pregnancies). In a group for male survivors of childhood sexual abuse, a common misconception among members is that they “must” be gay because a man abused them. The worker helps members understand that sexual abuse of children is not about the child’s sexuality, or about sex at all; like adult rape, it is about the perpetrator’s need for power and control and reflects that person’s deep feelings of inadequacy. Visualizing. Graphic presentations can illuminate heretofore-unidentified patterns of relationships and behavior. As we discussed in chapter 5, genograms portray family trees over several generations, including illnesses,

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occupations, nicknames, and migrations. Similarly, ecomaps delineate the complexity of people’s transactions with the environment. For people who are primarily visual learners, graphic representations especially enhance understanding. Visual representation of a family history of behavioral and mental health problems, like substance abuse and depression, have been found to help clients acknowledge and understand current problems that reflect family behavioral patterns and genetics (Goodman, 2013; Newman, Burbach, & Reibstein, 2013). Offering suggestions and advice. The worker may become an important teacher of emotional and cognitive skills. Workers can offer suggestions and advice about ways of managing life transitional stressors that reflect clients’ unique experiences, needs, and situation. At first glance, suggestions and advice may appear to be the same. We suggest there is a difference—which in some cases may be subtle—between suggestions (based upon the worker’s theoretical and evidence-guided knowledge) and advice (which often reflects the worker’s personal opinions). Consider the following example of a suggestion offered by a social worker. Natalie is a 35-year-old woman who has been seeing a social worker to help her deal with the recent passing of her parents, both of whom were killed in a car accident. The client’s struggle to grieve the loss of her parents was complicated by the fact that when she was a child, her father sexually abused her. Natalie believed that her mother had some idea that her father was abusing her but did nothing about it. She has been in counseling previously; she believed that she has been doing well, but her parents’ death has “thrown her for a loop.” Natalie had never discussed her sexual abuse with her parents but had always assumed that she would do so. As a part of her grief work, the social worker suggested that Natalie write her parents: “You understandably have much hurt, anger, and unfinished business with your parents. One thing that is often helpful to survivors is writing a letter to the people who have hurt them, not protected them. Do you think that might be helpful to you, to put into words what you would like to have been able to say to your parents?” The worker’s suggestion is based upon conceptual and empirical literature that supports the value of letter writing—an activity that allows clients to share reactions, opinions, and feelings about individuals (alive or not) in a nonthreatening way. In some instances, the worker offers advice, which reflects a more common-sense approach to addressing the client’s challenges. The worker might advise a client who wishes to go back to school but worried that she is “too old” to consider auditing a class to “get her feet wet.” Or, in addition to other interventions with an older, retired client struggling with depression, the worker

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might advise him to consider volunteering at a local humane society after learning about his love of dogs. In seeking or accepting an offer of social work services, clients often expect that they will be offered direction about what to do to resolve their difficulties, and they are dissatisfied when such direction is not forthcoming. Many students (and practicing social workers) have assumed that they should never offer advice and suggestions to their clients. In fact, research indicates that clients benefit from their worker providing them with direction, advice, and opinions (Gingerich & Peterson, 2013; King, 2015; Wodarski & Curtis, 2016). However, when offering suggestions, and especially advice, social workers must avoid imposing their own values and coping styles on clients. Our offerings should be responsive to what the client is requesting and is prepared to hear, rather than to our need to tell the client what to do. Providing advice and suggestions requires that we remain in the world of is, not the world of should, as discussed previously. When offering suggestions and advice, we must do so in a way that encourages clients to try a new approach or way of thinking, but also allows them to dismiss our offer if it doesn’t suit them at that time. The practitioner determines how direct the advice should be, depending on the severity of the issue and the person’s level of anxiety or impairment. The advice can range from suggesting, to urging, to warning, to insisting (in situations when clients’ actions might be harmful to themselves or others). The social worker also considers clients’ willingness and ability to ignore the offered advice and suggestions and tell the worker so. Even if we frame these offers as just one more source of information that clients can attend to or disregard, some clients will follow our suggestions out of a desire to please us, because they are unclear about what they themselves want, or both. Our advice and suggestions should promote empowerment and autonomous decision-making, not foster clients’ dependence on us to make decisions for them. In situations that involve more critical and life-altering decisions, we may need to refrain from offering advice, even when we are asked. A client living in a shelter for victims of domestic violence struggled with whether to leave her partner and asked one of our students, “If you were me, what would you do?” The student was unsure how to respond, although she acknowledged later to her classmates that the answer seemed obvious to her: “Leave the bastard!” The student understood, however, that what seemed obvious and straightforward to her was far less clear to her client. What she said was, “I understand why you might want me to tell you what to do, or what I would do if I was in your situation. But I’m not in your shoes. Only you can make this decision. Perhaps we can talk about the pros and cons: Why stay and why leave?” This intervention

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leaves room for the client to explore the life-transitional stress related to separation and moving from what is known and familiar (if unpleasant) into the unknown and unfamiliar. She avoids a common misstep that workers make, which is to prematurely move to solutions rather than exploring in sufficient depth the life-transitional stress. Engaging in activity. As we discussed in chapter 7, activities can be valuable icebreakers because clients often find it easier to talk while doing something. For some clients, particularly children, adolescents, the aged, and developmentally challenged adults, activities can be an important means through which the work takes place. Alonso, one of our students, was placed in a program to assist adolescents aging out of the foster care system. This life transition presented numerous challenges to the adolescents; upon turning 21, they would be on their own, required to care for themselves after living with foster families or in residential facilities, in many cases for years. Alonso facilitated a “chat and chew” group, in which members learned to read recipes and prepare grocery lists and meals. Through these meaningful activities, members developed comfort with one another, and as a result, they also began to provide support to one another and discuss their feelings about leaving the foster care system. The student worker understood that the cooking activity was both the goal of group members’ work together and a means of developing cohesion and fostering support with the life transition. Expressive techniques. Many clients need help with expressing and/or managing feelings (Chorpita et al., 2011; Slayton, D’Archer, & Kaplan, 2010). Activities ranging from art and music to relaxation, journaling, and reading assist in this area. The chosen technique should be tailored to the needs, comfort, and developmental level of clients. One very widely used activity is coloring, which provides clients with a means of soothing and comforting themselves, as well as a way of expressing feelings. Until recently, coloring books existed only for children, which made their use with adults problematic. Coloring books now are widely available for clients of all ages, providing them with a way to “color out” feelings. For example, when clients forcefully use crayons and ignore coloring lines, this can be a way of expressing anger; clients who carefully outline an illustration on the page and gently color within the lines may be using the activity to relax and control their otherwise overwhelming feelings. Recent examples of our students’ use of techniques to help clients express and manage feelings include the following: • The student led a karaoke group for seniors in an assisted living facility. Members took turns singing songs from their past. This fostered connectedness, laughter,

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and empowerment as members reflected on times when they were more in control of and experienced happiness in their lives. • The school social worker brought in comic books featuring superheroes to engage an adolescent mandated to see him due to academic and behavioral difficulties. The comic books enhanced the client’s reading skills and provided a means for him to talk about and work through his anger at being bullied. • The social worker in an inner-city hospital was able to secure art materials that she made available to individual clients and group members who lost a loved one to gun violence, including modeling clay, crayons, markers, scrap paper, and pillows. Her clients could use whatever items they wanted when they needed to express their grief, particularly feelings of anger.

Using role-play. Role-play is a distinctive participatory activity that can be used to assist clients in dealing with life transitions. It provides an opportunity for clients to view themselves and their experiences from a different perspective (Harper & Singh, 2014; Shahar et al., 2012). Clients who have been exposed to a traumatic event can be helped to see themselves as survivors rather than victims. For example, using a role-soliloquy, the client identifies and reenacts behaviors she engaged in that allowed her to survive her abuse as a child and protect a younger sibling from maltreatment, which reveals her courage and strength. Earlier, we presented a variation on the use of role-play, when we described the worker’s efforts to help Natalie come to terms with the death of her father—who had sexually abused her and her mother, who she believed knew what her father was doing—by suggesting she write a letter or talk to them. This allows the client to express thoughts and feelings about his parent’s passing as a way of achieving closure. In the next chapter, we examine in more detail how role-plays can be used to enhance clients’ social competence in engaging the environment. Specifying actions and identifying steps for task completion. Social workers may need to help clients identify the specific steps that they will need to take to master the life transitions that they are facing. For example, a young gay man, Grant, was uncertain about whether to come out to his parents. The worker, Beth, helped him explore his ambivalence and identify his anxieties and fears. Ultimately, the client decided to disclose his sexual orientation to his parents. In our discussion of inviting self-reflection earlier in this chapter, we introduced readers to a client who has been in a series of relationships with men that have been emotionally abusive. We suggested that the worker could help the client see this pattern, as well as reflect on why she enters such relationships in the first place. Further, we cautioned that insight might not be enough to lead to changes in behavior.

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In this case, as the worker and the client, Annamarie, discussed the reasons why she tended to choose the same type of man to date over and over, and it became clear that she grew up in a household where nothing she did was ever good enough for her father. She described him as cold and distant. The worker and client agreed that as an adult, Annamarie continued to believe that she would never be good enough for a man, and so she entered relationships that supported and reinforced this belief. As important as this realization was, however, it was not enough to prompt Annamarie to do anything differently. In the next chapter, we return to both of these cases to discuss how workers assist clients in taking concrete steps that help them better navigate and interact with their social worlds. Assigning work outside of session. Research indicates that when we provide our clients with assignments or tasks to complete between sessions, this enhances motivation, as well as increasing the likelihood that our work together will be successful (Kazantzis, Whittington, & Dattilio, 2010; Mausbach, Moore, Roesch, Cardenas, & Patterson, 2010). Homework assignments build upon and extend the work done in the session. Between-session tasks also bridge the gap between what is done in the limited amount of time we have with clients and the rest of their lives. For example, the client was a male victim of childhood sexual abuse who was being seen in an addiction treatment program. He struggled with his beliefs that he was some sort of “freak,” since sexual abuse was a “woman’s problem.” The worker provided the client with a book written by and for male survivors and asked that he read a chapter before each session, so that they could talk about what (if anything) he had learned from it. This encouraged the client to begin to explore the connection between his addiction and the trauma of his sexual abuse. While “homework” is a widely used term to describe the assignment of tasks, we remind readers that this is not analogous to assignments that are required in academic settings. Clients (and their workers) must recognize that assignments are designed to extend the impact of their work and promote autonomous actions and more successful coping. If an assignment is not completed, clients have not “failed.” The worker and client must revisit what happened: Was the assignment not helpful or not the right one? Was the client ambivalent about performing the task? Was there not enough preparation to help the client complete the task? In other words, we assume that the client is not at fault—it is the assignment that needs to be refined. A solution-focused variation on homework requires that clients identify between-session change—that is, positive changes that have occurred since the

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Table 8.4 Guiding Skills • Provide relevant information: 0 Correct misinformation. 0 Provide visual aids. • Offer advice and suggestions. • Engage in activity: 0 Use expressive techniques. 0 Use role-play. • Specify actions and identify steps for task completion. • Assign work for the client to do outside of sessions.

last time that the worker and client met (Berg & DeJong, 2008; deShazer, 1988; Knight, 2004). Essentially, the worker asks the client, “During the week, I want you to think about and identify one thing that is going better for you now than when we first started working together. And we’ll talk about it next time, okay?” This can be varied, depending upon the client’s needs. The client can be asked to think back to the previous week (or some other time period) and identify something that is going better, is not as bad, etc. Readers should note the subtle message that this question conveys: something is better. This underscores the power of language, as discussed previously. Table 8.4 summarizes guiding skills. Facilitating Skills

As discussed in chapters 6 and 7, clients often approach us and the help that we have to offer with ambivalence that can undermine their ability to take the steps needed to successfully resolve challenges associated with life transitions. Further, as discussed in chapter 5, clients’ motivation to change and engage in the necessary work may be limited due to a variety of factors, including a belief that change is not possible. Even when we believe that we have established a working agreement, clients may be reluctant to work on difficult life transitions, since this may require them to reveal, share, confide, and explore deeply personal and often painful experiences. Workers employ four facilitating skills address clients’ reluctance to move forward. Identifying avoidance patterns. Using this skill, the social worker makes an explicit and direct statement about a pattern that a client is exhibiting and its self-defeating consequences: “Each time we meet, you say you’re going to contact the psychiatrist I suggested to see if maybe you are having a problem with feeling depressed, but then when we meet again, you haven’t done it because you

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say you forgot or didn’t have the time”; or “I notice that very time we begin to talk about your son’s coming out to you, you change the subject.” In many instances, we will have to go further and use our empathy skills. In chapter 7, we discussed the skill of putting clients’ feelings into words, and this can include reaching for feelings of ambivalence. In the first example, the worker might have to add, “I’m wondering if it’s not so much that you forgot or didn’t have time, but that you are still having trouble accepting that you might have a problem with depression.” In the second example, the worker might say, “You’ve made it clear that you love your son—and I believe you’re sincere—but I wonder if maybe it’s still hard to accept that he is gay, given your religious beliefs?” Responding directly to discrepant messages. Addressing clients’ avoidance may require us to point out discrepancies between verbal and nonverbal messages. Clients may not be aware of the mixed messages they are sending. Therefore, the worker makes the contradictions between clients’ verbal and nonverbal behavior explicit, in order to help them address and work through their avoidance. For example, in an outpatient substance abuse treatment program, the worker comments, “I am concerned—you’re telling me you stopped drinking, but I can smell the alcohol on your breath.” Readers might initially interpret this comment to be accusatory. Whether the client experiences this as critical or supportive will depend upon the worker’s tone of voice and accompanying nonverbal behaviors. If the client still is drinking, the worker must, out of concern, directly deal with this. We will not be helpful to a client in the precontemplation or determination phase of change if we don’t acknowledge this reality. In a neonatal intensive care unit (NICU), the worker observes to a new mother, “I can tell that you are having trouble, and I would like to help you. You said you wanted us to bring your baby to you, but now that she’s here, you don’t want to hold her.” When said with empathy, this comment encourages the mother to think about her contradictory behaviors. The worker may have to go even further, putting into words the client’s possible ambivalence and the fear that her behaviors may reflect: “New moms are often scared to hold their babies, because they are so small and seem so fragile. Maybe that’s how you’re feeling? Sometimes new parents also blame themselves for their baby’s prematurity, and that also can make it hard to be with your baby.” Challenging the appearance of commitment. An especially challenging manifestation of avoidance, particularly for novice social workers, is superficial compliance by clients. A client goes through the motions of working on agreedupon goals, but nothing really changes. The reasons for avoidance include what we already have discussed. The difference is how the avoidance is manifested: clients appear—sometimes intentionally, sometimes unintentionally—to be

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working toward goals to which they have committed. Students often struggle with addressing this form of avoidance directly. They, too, may desire to maintain the illusion that something meaningful is taking place, since the alternative—confronting the client—is uncomfortable. If we are going to be helpful to our clients, though, we have an obligation to address this behavior. We suggest that workers be “sensitively direct” to underscore how important it is for the worker to have the courage to avoid avoidance. Contrast the two scenarios described by two of our students who were faced with their clients’ avoidance: • David was working in a youth diversion program with juveniles who were court-ordered to attend it, in lieu of incarceration in an adult correctional facility. His client, Jamal, had been charged with carjacking and was required to attend school, participate in an anger management group at the agency, and meet weekly with David. Jamal initially was reluctant to engage with David and expressed much anger and resentment about his mandatory participation in the program. However, he did agree to work on the court- and agency-defined tasks because he did not want to go to prison. In their seventh session, David observed that Jamal had missed the previous two meetings and informed him that the school reported that Jamal had stopped coming. Jamal angrily responded, “It ain’t no big deal. Why you can’t just leave me alone, motherfucker?” David’s fellow students gasped at his client’s response and expressed relief that Jamal was not their client. • This prompted Kara to exclaim, “I sure wouldn’t want a client to cuss at me like that, but I’ve got a client who’s really pissing me off!” Ms. Jackson, a single mother of three children, lost custody due to her drug use. The goal, reunification, was one to which Ms. Jackson expressed commitment. She was required to attend weekly Narcotics Anonymous (NA) meetings, find a sponsor, and follow up on a referral for counseling to address the sexual abuse she had experienced in childhood. Kara visited the client in her apartment twice a month. Three months into their work, Ms. Jackson had yet to follow up on the referral for counseling, attended NA meetings only sporadically, and had yet to find a sponsor. In their last several sessions, Kara identified the avoidance patterns, but Ms. Jackson continued to maintain that she “really, really” wanted her children back and promised by their next session, she would follow through on these tasks.

We understand why students expressed discomfort in response to David’s experience with Jamal. However, Jamal handed his worker a gift of sorts. David did not have to reach for Jamal’s ambivalence about committing to working with him. Jamal openly expressed his feelings to David. Ms. Jackson, on the other

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hand, continued to tell Kara that she was on board with the plan, even though her inaction conveyed precisely the opposite. The illusion of involvement does not exist only when we work with mandated clients, as in these two examples. In a previous example, we described the worker’s attempt to identify avoidance with a client referred to a psychiatrist for evaluation for depression. The client in this case was voluntary; she sought services from the worker’s agency due to her recent loss of a job and the ending of a relationship with her longtime partner. The client was open to talking about her sadness but had difficulty accepting the possibility that she might be clinically depressed because in her culture—she was of Chinese descent—mental illness was taboo and carried with it a stigma. Generating discomfort. To help clients who avoid painful realities, such as an imminent eviction or prison, the social worker might attempt to create some anxiety in order to promote the motivation that they need to truly commit to the work. For example, in his next session with Jamal, David said, “Look, Jamal, I get that you are pissed off at having to do things that you think are BS. But let’s get real here. If you don’t go to school and come here, you’re going to prison. Adult prison. And I won’t be able to stop that from happening. It’s all on you now. I can help you take the next steps, but I can’t take them for you. So what’s it going to be?” In her next session with Ms. Jackson, Kara said, “Ms. Jackson, I must tell you that you can’t keep saying you are going to do something and then not do it. We want to do what’s best for you and your children. That means we can’t continue to plan for you to get your children back if you aren’t going to do the things that are needed to make sure they are safe.” In both examples, the student workers challenged their clients’ defenses out of concern and caring, not anger (though both students acknowledged feeling frustrated by their clients’ behavior). David’s demand led to a deeper exploration of why it was that Jamal sincerely wanted to avoid prison but hadn’t been able to follow through on the required tasks. His feelings of hopelessness and despair led him to assume that nothing he could do would save him from the fate of his father and two older brothers: incarceration. Using empathy and motivating skills, David was able to help Jamal renew his commitment to the work that he needed to do to avoid prison. The outcome of Kara’s demand for a commitment from Ms. Jackson had a very different outcome. Kara’s comment was met with silence. She asked about the meaning of the silence, and Ms. Jackson began to cry, saying, “They’re [her children] too much for me. I can’t handle them. I want to, but I just can’t!” After some hesitation, Kara said, “You’re saying that you don’t want your kids back?”

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Table 8.5 Facilitating Skills • Identify avoidance patterns. • Respond directly to discrepant messages. • Challenge the appearance of commitment. • Generate discomfort.

Ms. Jackson tearfully nodded. Kara replied, “Wow, that’s gotta be a really hard thing to admit. Takes a lot of courage to say that.” Ms. Jackson and the worker spent the remainder of their session discussing her disclosure, and by the end, both agreed that reunification was not a reasonable goal at this point. Kara was understandably disappointed at her client’s response, but she remained in the world of is. As taboo as Ms. Jackson’s feelings might be—a mother is “supposed” to love and want her children—if that is how she feels, it is better for her children’s well-being (who are the real clients in this situation) if Kara works with this reality and plans accordingly, rather than maintain an illusion that mother and children will be reunited, at least for now. These interventions challenge avoidance and ideally stimulate and mobilize clients’ energy and motivation for work. They will be helpful only if trust and confidence in the worker’s caring have been established and the worker makes demands in a nonaccusatory way. Thus, these skills should be used selectively and with caution. This will require that workers attend to their feelings about their clients’ avoidant behaviors. Otherwise, they are at risk of using these skills punitively, which will intensify rather than reduce the clients’ defenses and increase the likelihood of their dropping out. Table 8.5 summarizes the facilitating skills. Trauma-Informed Considerations

All the skills presented in this chapter will be relevant when clients have a history of trauma. We previously observed that working with trauma survivors can be challenging when they seek or are required to seek assistance with present-day stressors rather than past trauma that might be lying beneath the surface. Five considerations provide guidance regarding how to use the skills that we have discussed, and also to work within one’s agency-defined role to address trauma survivors’ issues. The worker’s efforts might be primarily or solely focused on current stressors. However, as trauma survivors are helped to successfully manage these stressors, this enhances feelings of mastery and self-efficacy that are consistent with the trauma-informed principles of empowerment and control.

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Providing Information

Many clients with trauma histories are unaware of the connection between their past experiences and current problems. Therefore, providing information takes on added significance. In a previous example in this chapter, we described the homework that a student assigned to his client who had been sexually abused; he was to read a book written by male survivors about their experience. Reading about other men just like him helped this client understand the nature of sexual abuse, which reduced his feelings of being alone and a “freak.” In chapter 7, we introduced readers to a social work student named Kathleen, who worked in a shelter for victims of domestic violence, and her client, Sofia. Readers will remember that the client disclosed a history of sexual abuse in response to a question posed by Kathleen. Sofia further disclosed that she had been a victim of violence in relationships prior to her current one with boyfriend, Carlos. Using the skills of pointing out patterns and providing information, Kathleen helped Sofia see how her past sexual abuse set her up to seek out men who mistreated her, reinforcing her beliefs about herself as worthless and unlovable. Suggestions and Advice

Survivors of trauma—particularly childhood victimization—usually struggle with low self-esteem and feelings of inadequacy. This may result in them wanting the worker to tell them what to do. Therefore, it is especially important for workers to adhere to our recommendation that clients must be willing and able to refute the worker’s proffered guidance. Workers may need to specifically reassure trauma survivors that they need not adhere to any suggestions they offer and encourage clients to develop their own opinions, consistent with the principle of empowerment. Correcting Misinformation

Because survivors often hold distorted views of themselves, others, and their experience, the skills that are essential to challenging these distortions are sharing our insights, correcting misinformation, and providing our interpretations. In a previous example, a social worker challenged his client, a male survivor of sexual abuse, about his beliefs that he was to blame for his abuse, that he “must be gay” because his abuser was an uncle, and that he was unattractive to women.

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Reaching for and Helping Clients Manage Their Feelings

Consistent with the two principles of trust and safety, social workers employ empathy skills to convey understanding, support, and acceptance. Because survivors of trauma may have utilized repression of feelings as a tool to cope with their experiences, reaching for feelings may be especially helpful. Our use of empathy must be consistent with the trauma-informed principles of empowerment and control. There are three implications of this. First, clients with trauma histories may become overwhelmed by their feelings, which in turn undermines competence and self-efficacy. Expressive techniques may be needed primarily to help clients contain—rather than express—their feelings. Coloring and journaling might help clients “self-soothe” when they begin to become overwhelmed with emotion. Second, in a variation of behavioral rehearsal and homework, workers can help clients develop techniques to relax when stressed. This can include asking about exceptions: “Tell me about a time when you were feeling calm and relaxed” or “. . . less stressed.” Finally, because survivors of trauma often experience intense emotions and disclose painful experiences, workers may be tempted to provide physical comfort as a means of conveying empathy. Because survivors’ trauma may have involved the misuse of touch, the considerations about touch presented in chapter 6 must guide our decisions in this regard. It is critical that trauma survivors have control over whether and in what way they have physical contact with their social workers. This should include considerations associated with physical space—the distance between our clients and ourselves when we meet, and between our clients and others in the case of family and group work. Motivating Skills

Exposure to trauma often leads individuals to feel powerless. Therefore, they are likely to assume that they have no control over their current situation and/ or that any effort they undertake to manage it will be unsuccessful. Kathleen’s work with Sofia required her to use a number of these skills, since Sofia was unable to see a way out of her abusive relationship. Her abuse as a child, coupled with the ongoing violence she experienced in her adult intimate relationships, reinforced her feelings of powerlessness and worthlessness. To counter Sofia’s sense of hopelessness, Kathleen pointed out her strengths, the most important one of which was Sofia’s willingness to seek shelter at the agency, and she helped Sofia identify options available to her, which was reassuring and conveyed hope.

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As Sofia’s agency-defined three-month stay at the shelter progressed, Kathleen helped Sofia identify the next steps she could take: providing her with information on an order of protection; settling on a safety plan if she decided to return to her boyfriend, Carlos; and developing a résumé and beginning a search for employment as a way of lessening her dependence upon Carlos. The majority of Kathleen and Sofia’s time in session was spent on the current stressors in Sofia’s life—the domestic violence—not the sexual abuse. Kathleen used mobilizing, empathy, and information-sharing skills to validate the trauma associated with Sofia’s sexual abuse, explain its association with Sofia’s current stressors in living, and encourage her to follow up on a referral to a counselor in her community to address her sexual abuse.

STRESSFUL LIFE TRANSITIONS: PRACTICE ILLUSTRATIONS

Up to now, we have identified a range of skills that help clients think, feel, and do things differently. How practitioners use these diverse methods and skills depends on their and their clients’ individuality, as well as workers’ creativity and experience. We now present several extended examples of our students’ practice to illustrate how we can help individuals, families, and groups with difficult life transitions and traumatic events. Prentice: The Thinking-Feeling-Doing Connection

Prentice is a 16-year-old, African American male who resides in an impoverished inner-city neighborhood with his paternal grandparents and his older sister, Brenda, age 18. Prentice’s grandmother referred him to an outpatient mental health clinic. She was concerned about his angry outbursts at home, as well as academic and behavioral difficulties he was having at school. When Prentice was 2 years old, his father left the family. Prentice and Brenda were removed from the home when he was 8 years old due to their mother’s neglect and addiction to drugs. They were placed with his grandparents, who assumed legal guardianship. Their mother maintained weekend visitation for a few years, and then her contact with the children became inconsistent. Prentice has not seen or heard from his mother for the last four months. In the first session, the worker reports that Prentice is open and easily engaged. He acknowledges difficulties at home and school and describes his grandmother as “caring, but too strict.” He complains about “too many house rules,” which has resulted in frequent arguments. He expresses “feeling pissed off

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a lot,” but he says that he wanted to reduce conflicts between his grandmother and him. After three sessions, Prentice begins to express feelings of loss and anger about his mother’s lack of involvement in his life. He had hoped that his mother would petition the court and resume full custody of him. However, over time, he began to realize that his mother was either unwilling or unable to care for him. He states, “She always breaks her promises, and I know that she never will be a real mom.” During the fifth session, Prentice begins to talk about his anger, but not his sadness. In the sixth session, the social work intern invites Prentice to talk about his life experiences with his mother. He shares his memories as a young child of his mother being frequently high: intern: So you remember Mom using? prentice: Yeah, she would stumble around the apartment and yell at us, and then somehow Grandma would always have to come over and get us. intern: What was it like for you watching Mom stumble around the apartment and yelling at you? prentice: I don’t know . . . I sometimes wondered if it was something that my sister and I did? intern: What do you mean? prentice: Well, I just wonder if me and my sister had been better, then Mom wouldn’t have had to get high, maybe we wouldn’t have had to leave, and then we would still be living with her now. Things could have been different. intern: You think if you and your sister had been better, your mom would not have used, and you would still be living together? prentice: I don’t know . . . (looks down at the floor, shakes his leg). intern: I don’t think two small children could do too much to help a mother not to drink. prentice: I guess, but if she had gotten clean in the beginning, things would be different. But, maybe not, ’cuz she’s been clean now for a while and she still don’t want us. I just wanted to help her. She don’t take responsibility for anything. I wish I could have lived with her so I could have helped her with stuff. intern: What could you have helped her with? prentice: I could have told her she needs to get a job, save money for a car so she could give my grandma money to support us, and she could drive over and pick us up instead of Grandma driving over to her place all the time. Well, actually to drop me off because Mom couldn’t deal with both my sister and me at the same time because we was too much for her to handle at once. intern: Wow! You’re putting a lot of responsibility on your shoulders.

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prentice: I do. I love her, but I hate her. Well, I don’t hate her really. I just wish she could be different. I wish everything could have been different. intern: I understand—you have mixed feelings about your mother and miss her. prentice: I feel bad . . . I keep thinking that if I never yelled at her on the phone, cussed her out, everything would be fine. intern: I feel terrible that you blame yourself so much—your mother was supposed to take care of you, not the other way around. Prentice is silent. intern: What are you thinking, Prentice? prentice: She is supposed to be the mother (getting teary-eyed). intern: Yes, she was supposed to be the mother, and you the child. prentice: Yeah, but how do I stop thinking about her, hoping she’ll call me again? intern: (Pats client on the hand) I’m sorry, Prentice, this is so tough for you. Silence as Prentice softly cries. intern: We can help you manage your feelings, so it doesn’t hurt so much. How about if we also help you develop ways you can manage the uncertainty of your mom? I’m thinking that maybe one of the reasons you’re getting in trouble is you’re never sure whether you mom is in or out of your life? That can be crazy-making.

Here, Prentice conveys his intense guilt, self-blame, helplessness, and longing for his mother’s love. The social work intern helps Prentice begin to grieve the loss of his mother by using elaboration, clarification, empathy, and exploration skills. She encourages Prentice to re-create his experiences of living with his mother during childhood to help him express his profound loss and to challenge his long-held belief that it was something he did or did not do that led to her neglect. The intern acknowledges his painful feelings and creates a safe place for their expression. She also suggests that they devote time to helping him develop ways of coping with his mother’s unpredictability. Bereavement Group: The Power of Mutual Aid

The next example demonstrates the helpfulness of mutual aid in a group for bereaved individuals. A social work intern formed the group for people who had experienced the death of a spouse or parent. The group’s purpose was to provide members with a safe, supportive place where they could help each other deal with their losses. The group was offered by a hospital and met one night a week for six weeks. The group was composed of four members who identified as African Americans, three individuals of Mexican descent, two Korean Americans,

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and five white members. A total of 12 members were female, and 2 were males, with ages ranging from the twenties to the seventies (most members were in their fifties). The group was heterogeneous in terms of age, ethnicity, religious affiliation, and socioeconomic background. The profound commonality of losing a loved one made their differences in background inconsequential. The members who lost a spouse or life partner felt alone and incomplete. The members who lost a parent felt the loss of their longest consistent, often precious relationship. A common stressor for the members was the pressure they received from friends and relatives to bury their grief and to move on with their lives, which added to their adaptive burdens. A vignette from the third session follows: jennifer: I hear what my family and friends are saying. But I don’t understand how I can simply forget my mother and go on with my life? intern: Your friends tell you to forget your mother in order for you to move on? jennifer: That’s how they make me feel (begins to cry) . . . I don’t want to forget her. We loved each other. intern (looking around the room): Do others feel the pressure to forget and get over your grief? eva: No matter how hard I try, I can’t forget and I won’t. The others verbalize their agreement. joan: I feel like I have to forget my mother, place her behind me, or I’m never going to be okay again, but I think about her all the time. intern: Maybe you all can stay connected on some level while still trying to go on with your lives. gina: Yeah, I never want to lose that connection. I mean, I know my husband is dead, but he was a huge and important part of my life. How could I ever forget him—why would I ever want to forget him? betty: (nods) If I forgot my husband, it would be like he never existed—like my life never existed. Why do people want us to forget? george: Maybe they think that by telling us to forget, our pain will go away. They don’t realize that they increase our pain. intern: Right. And maybe they are struggling themselves, or don’t know what to say? The intern notices that Debbie looks like she wants to speak. Tears are streaming down Debbie’s cheeks. Debbie, you are feeling a lot right now. debbie: Everyone is talking about forgetting, but I can’t forget my husband. Maybe I am crazy, but I feel him with me all the time. At night, I wait for the door to unlock at 6:30. I even hear his voice. There must be something wrong with me?

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gina: If there is something wrong with you, then there is something wrong with me too. I’m sure I’m going nuts (laughs). My husband loved his car—he had it washed every week. Well, I was out driving it the other day, and I realized that the car had not been washed in several weeks. I heard his voice asking why I hadn’t washed it lately. So if anyone is crazy, it’s me. The group members laugh. intern: It is very common to feel a sense of presence or to hear the person saying things that they said before. It’s how we all handle loss. I know I did when I lost my father. gina: (Laughing) Whew . . . So you mean I’m not going nuts. intern: Certainly not, but worrying about going nuts must be scary She looks around the room. linda: I don’t feel my husband’s presence or his voice, but I want to. I want to remember him and feel his presence more than anything, but I can’t. I only remember his sickness and his pain because his illness lasted so long. I find myself talking to him, asking him to let me know that he is out of pain. I also ask him questions every day. I just wish he could answer me. The group members are silent. The intern stays silent too, so they can all process what just had been discussed.

Group members movingly expressed the depth of their pain and confusion. They yearned for their loved ones but felt that they couldn’t express their feelings and thoughts to family members and friends. The intern encouraged mutual aid and support by refraining from commenting when members could do so themselves. She reframed the members’ experiences as a way of normalizing them, which freed members to work through their grief. She also engaged in a limited use of self-disclosure, which is another way of normalizing members’ experiences. In the fourth meeting, group members brought in photos or mementos of their loved ones to share with the group. In the fifth session, Debbie began the meeting with the photos that she forgot to bring the previous week: debbie: I remembered my pictures this week (she pulls them out and shares them). The group members silently look at them, then start talking among themselves. intern: How was it for all of you to share your pictures and mementos? We didn’t get a chance to process this last week. eva: It was good, but I’m glad it’s over. betty: I agree. linda: It is still hard for me to look at his pictures.

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marta: I agree, he looked so healthy and alive—it’s hard to imagine. joan: Yeah. It was hard to look at the pictures because it was the first time I looked at them since my mother died, I am glad you all suggested it because I ended up feeling good. I decided to leave them out to look at every now and again. intern: You had mixed reactions . . . jennifer: I left my pictures out also. I thought it would make me sad, but it didn’t. I was surprised that it brought me great joy. I could see the sparkle in my mother’s eyes. I loved that sparkle. george: I need to ask you a question (looks at the intern). When does the presence of somebody leave your memory? intern: I am not sure what you mean, George—could you explain what you mean? george: What I mean is, how strong should a deceased person’s presence remain with you, and for how long? intern: I think for each of us, it’s different. How strong is your wife’s presence for you? george: I was going through some things in the basement, and I ran across some of my wife’s things—the pictures (his voice cracks) and some invoices from her business. Anyway, it was like she was standing right next to me—I could feel her presence so strongly—it was like I could touch her (a tear runs down his cheek), but I couldn’t. gina: I feel my husband’s presence all the time. It is comforting to me. I don’t want to lose it, but I am scared that it will decrease over time. It probably has already. linda: (looking at George) We all experience things differently—no one can tell us how long it will last. You need her presence now, but maybe not later. george: I really do need her right now—I miss her terribly.

The members discussed the need to keep an active connection rather than forget their loved ones, as others had urged them to do. They learned from and reassured each other that their grief responses were normal. The social work intern gently encouraged exploration or wisely stayed out of the way of the free-flowing mutual aid processes. Rather than answering George’s question (a question to which there really is no definitive answer), she affirms how individual the grieving process is. She disregards an understandable desire to minimize members’ pain by offering an unrealistic estimate about how long it will take for a loved one’s presence to diminish. Sex Education Group: Respecting Clients’ Sense of Urgency

An educational group for young gay males (15 to 19 years old) was led by a social work intern who himself was gay. 2 His agency—an outreach health and social

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service program for the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community—formed an educational group to provide information about safe sex and harm-reduction behaviors. The group members were sexually active and had been deemed to be at high risk of a sexually transmitted disease by their primary care providers. All members were engaged in unprotected sex with friends and anonymous partners. A curriculum was prescribed that would encourage the members to reduce their self-destructive, potentially dangerous behaviors. In this 10-session group, three group members were white, two Latino, one African American, and one Asian American. The members readily described their high-risk behaviors as passive partners of anal intercourse or active partners of oral sex without condoms. While they all agreed to try the group, they were not invested in changing these behaviors. After actively describing their sexual experiences and behaviors in the first session, they began to lose interest in the intern’s presentations and began to withdraw. When the intern shared his difficulties with the group in class, he was encouraged to pay greater attention to the group members’ underlying pain, which might explain their risky sexual behavior, and to the group’s potential for mutual aid. As the intern integrated the curriculum content with the members’ own expressions and concerns, the group’s mutual aid processes became powerful forces for healing. The members’ feelings about loved ones’ reactions to their sexuality had a powerful and painful impact on them, as this excerpt from a session and described by the intern reveals: han: I had a really shitty day yesterday. I told my parents that I was not going to college after I graduate high school, and they became really upset. They want me to go to college, get a good job, get married, have kids, take care of them. They think I am lost or something. My mother was crying, and she never cries. I didn’t expect it. They’ve been worried about me. They told me that I am not the son they wanted me to be and that I had disappointed them. I emphatically shook my head from side to side. han: They think I am not going to get anywhere in life because I am gay. Ever since I came out to them, they think my life has gone downhill. They think I have all of these negative influences in my life, and that the negative influence made me decide not to continue with school. I’m so pissed at them, but it’s hard because they have done so much for me. Silence. John, Mike, and Maurice exchange glances indicating they understand. intern: I see you guys nodding your heads. You know exactly what Han is talking about?

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maurice: (nods) I feel the same way. (looks at Han). I get you, man. I am so angry with my mama, but it is hard for me to be mad because she gives me a place to stay. I can’t help it. Whenever I am at home, there is all this tension, and I know I am the cause of it. intern: What do you think the tension is about? maurice: I guess I am tense because she don’t really accept me. Like sometimes when we are all at home and watching some TV, a show comes on and there is the token gay character. You know what I mean? The members laugh knowingly. maurice: Well, I always try to bring it up and talk about it. But she don’t want to discuss it. I really try to talk about it, but she just won’t. It’s like this wall comes down. Sometimes I push a little, but then she gets really tense, so I stop. It makes me mad. I mean as far as the gay thing. Like, OK, so I am gay, but it’s not like it’s the end of the world. intern: It really hurts not to have your parents accept who you are. I think Maurice isn’t alone on this? shawn: My moms is great too, she really is, but I am mad at her too. I treat her like shit. She’s always been there for me, even when my boyfriend died. I don’t know why, but I am just a total bitch to her. She’s all religious and shit and she don’t want all her church friends to know she got a homo for a son. intern: (looking at Shawn). So, what makes you so mad at her? shawn: I don’t know, I really don’t. I can’t help it. Do you know? With that question, all the members look at me. intern: I am not sure, but on the one hand, you guys are appreciative of the help your parents give you, but, on the other hand, you’re aware of their feelings— feelings that range from mild disappointment to total rejection. javier: My parents actually are sort of okay, but it’s my grandparents and my cousins. In my culture a man has to be “macho”—and being gay ain’t that. The members laugh. javier: My parents basically are, like, fine, be gay, but don’t let the family know. It’s a nonsecret secret, since I know my younger sisters know I’m gay and they can’t keep their mouths shut. han: Yeah, I have to live with my parents and they are financially generous with me, but not in their acceptance of who I am—I always see the disappointment and hurt in their eyes. Brief silence. intern: You know, most guys your age go through a rough time separating from their parents, but being gay makes it much tougher, much more confusing. You grow up having your parents love you, and then they find out you’re gay and

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you feel like you have to become someone else. You’re no longer the child they used to play with, protect, embrace. Their son is gay, and they experience it as a terrible loss. And you discover that their love is kind of conditional. And you also feel a powerful loss. What is like for you when your parents’ make you feel that you are not the son they had hoped for? shawn: It’s awful—the pain shoots throughout my body. (He looks down at the floor). john: (teary-eyed) Terrible doesn’t describe it—especially with my mom. We used to be so close before I told her, and now she treats me as if I don’t exist. A painful silence follows. Maurice and Han become teary-eyed. Maurice looks at me. maurice: It really hurts, you know what I mean? intern: I do know, and I think others do, too? john: I miss my mom so much. She used to play with me and love me. She always had gay friends, but when it came to me, she couldn’t accept it. Things have never been the same. (John continues to wipe away his tears and turns to the intern) Does it ever get better? intern: Yes, it does get better—we all find ways to heal. But I worry that you guys seem to be acting out your pain in very self-destructive ways—like punishing yourself through unsafe sex—like “my parents don’t care about me, so why should I care about myself?” maurice: You know, right now I feel better than I have in a long time, I really do. john and han (simultaneously): Me too! shawn: I feel much clearer—I didn’t hear any of your lectures on safe sex. Today I heard you, that you cared about me—about us. . . .

This courageous social work intern gave up the security and structure offered by a prescribed curriculum. He demonstrated faith in himself, in the group, and in the group process. He made the decision to work with the members and to fully involve himself in their lives. As a gay man, he identified with their struggles, recognized their loneliness, and identified with their pain from parental disappointment and disapproval. He himself had experienced the painful struggle of being true to oneself and one’s gay identity, and, consequently, of inflicting pain on one’s parents. Yet he never lost sight of the fact that in this group, he was the social worker, not a fellow member, so he used his own experiences—subtly and powerfully—to identify the members’ experiences. He understood and tolerated their pain, which in turn helped the group members begin to do the same. The social work intern served as an important adult gay role model, who skillfully helped members to help each other. Previous sex education had not

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reached them because it did not reflect their sense of urgency. As they explored their common painful experiences and their internalized self-punishment, they began to make connections between unsafe sex, their search for love and acceptance, and their fear of rejection. The social work intern employed enabling, exploring, clarifying, mobilizing, guiding, and facilitating skills and integrated them with genuine caring and personal style. He also used himself in a way that was helpful to the group members and was consistent with his role as the group leader. He harnessed the constructive and healing power of mutual aid to help members to help each other examine their risk-taking behaviors and consider changing these behaviors. The Wilkens-Gordon Family: Helping a Family Face a Difficult Life Transition

Letitia Wilkens and Katrina Gordon adopted their 4-year-old son, Theo, from an orphanage in Honduras three years ago through a private nonprofit adoption agency. With the ongoing help of the agency, Letitia and Katrina settled into their new role as parents, so services were terminated. Letitia and Katrina contacted the agency asking for help. For the first year and a half, Theo seemed to thrive and adjust to his new home and surroundings. His mothers reported that they first saw signs of a problem about six months ago, when Theo seemed to “withdraw” from them. While he was talking and increasing his vocabulary at a developmentally appropriate rate, his language skills began to regress. Alarmed, Letitia and Katrina sought assistance from their pediatrician, and ultimately from a child development specialist, who diagnosed Theo as being on the autism spectrum. The specialist informed Letitia and Katrina that while it was too early to determine the precise nature of Theo’s autism, she recommended that early intervention begin immediately to help him continue to develop his social, emotional, language, and cognitive skills. The mothers reported being “devastated” by the diagnosis, as well as “furious.” They claimed that they already had stressful lives and did not “bargain for a child with special needs.” They expressed ambivalence about what their next steps should be. They professed love for Theo, but they also questioned whether they were up to the challenge of caring for him. Despite their ambivalence, the mothers agreed to meet with the agency’s social work intern to help them adapt to their new reality, stating that they really did want to make it work. This arrangement was unusual, since the agency rarely offered follow-up services to adoptive parents and their children after the first six months. However, the agency director—also the student’s field

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instructor—believed that intervention was needed to prevent Theo from entering the child welfare system. The intern has had two meetings with Letitia and Katrina, in which she learned a great deal about Theo, as well as about his parents and their relationship with one another. The intern thinks that the challenges associated with parenting Theo and his recent diagnosis have exacerbated conflicts that already existed in their relationship. In the third session, the intern raises this possibility with them: intern: Over the last two times we’ve met, I’ve gotten the feeling that something else might be going on beyond learning about Theo’s diagnosis and all the stress that parenting him has created for you. I’m wondering whether what’s going on now might bring up some old stuff between you two? Letitia and Katrina look at one another, but remain silent. intern: So, maybe I have hit a nerve? I’ve never known you two to not have something to say (smiles). letitia: She (pointing to Katrina) never wanted a child in the first place! I was the one who insisted on it. I’ve always wanted a child. As much as I love her [Katrina], I wanted a child to make our family complete. Now I feel horrible that I brought this on us—our lives are already stressful enough! (Starts to cry) Silence. intern: This is really upsetting for you. It sounds like you are feeling guilty for “making” Katrina adopt a baby that she didn’t want? Letitia nods. intern: So, Katrina, you’re awfully quiet. I’m wondering what it’s like seeing your wife feeling so sad, so guilty? katrina: (Looks down and fidgets with her hands). She’s right. I didn’t want a baby. I didn’t think I’d be a good mom, since I had such a lousy mom myself. I liked our family just the way it was. Letitia, our two dogs, and me. Letitia begins to cry more heavily. intern: It’s hard to hear this, uh, Letitia? letitia: You bet. We fought about this for so long before we applied to adopt a baby, but I thought that we finally got on the same page. And now I see that we’ve never been on the same page—that was just wishful thinking on my part. You still wish we’d never adopted him! (Turns to Katrina) katrina: That’s not true! letitia: Yes, it is (raising her voice). katrina: It’s just hard, what with all his problems. letitia: (interrupting) He’s just a little boy! Our little boy (voice raised)! katrina: (interrupting) Yes, but he’s got problems! And we didn’t bargain for that!

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intern: Whoa. Letitia, Katrina, take a deep breath! Hold up a minute! I want to help you work through this. And that means I have to help you listen to and talk to one another. When you interrupt and talk over one another, neither of you is listening to the other. You’re both angry, you’re both overwhelmed, and I think maybe you’re both maybe mourning what you think you have lost. A “normal” little boy who would do all the things that little boys do. It’s like there’s a new reality—a new normal. And it’s hard to adapt to that.Katrina begins to cry.

The social work student’s actions in this session underscore how important it is to be in the world of is. When she met with her field instructor after this session, she acknowledged that she wanted to “make everything” all better for Letitia and Katrina. She wanted Katrina to want to be a mother to Theo. She wanted Theo to remain with his mothers rather than end up in the child welfare system. It is understandable that the student wanted these things. But instead of pushing her agenda onto the couple, the student sat with their pain, sadness, and anger. She introduced to them the possibility that there was “more to the story” than their reactions to their son’s diagnosis. As a result, Letitia and Katrina begin to reveal the longstanding conflict between them regarding becoming parents, which has resurfaced. The student understood that it was essential that the parents be able to work through this conflict, which required her to help them talk and listen to one another rather than interrupt and shout at one another. The social work student reframed her clients’ reactions, pointing out their shared feelings, including grief and loss. As this session progressed, Letitia and Katrina were able to talk more openly with one another about their responses to Theo’s diagnosis and what it meant for them. This discussion continued for the next two sessions. Letitia’s concern that Katrina never wanted a child in the first place resurfaced in the sixth session: letitia: I feel guilty and angry at the same time. intern: Guilty and angry how? letitia: If I hadn’t insisted we adopt, then we wouldn’t be facing this. But I really wanted a baby, and I thought Katrina finally decided she did, too. And now that we have a wonderful son, she wants to give up on him. intern: Let me interrupt for a second. Remember. . . . talk to Katrina, not to me, okay? Tell her about your guilt and anger. letitia: (looking at Katrina): I really thought you came around to my way of thinking. That you wanted to be a mom as much as me. That you loved Theo as much as me. Silence.

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letitia: (looking at Katrina). So, was I just fooling myself? Were you just going along with me? Did you just do this for me? katrina: No, not really . . . letitia: (interrupting). See, I told you so! I knew it. “Not really”? What the hell does that mean? You either wanted one or didn’t want one! intern: I know this is hard for you to hear, Letitia. I understand how angry you are, but how about you let Katrina answer your question? Katrina, I think Letitia needs to know whether you were on board with having a baby or not. Whatever the answer, it’s important that she know so that you both can deal with it. katrina: Right, so, Letitia, you’re right. I didn’t want a baby. I thought our family was just fine. But I knew how much you wanted one, and I love you, so I thought, “Okay, let’s do this, it will be okay.” But, I worried, worried a lot. intern: Worried? About what? Tell Letitia now what you worried about. katrina: Well, my childhood was shitty. My mom was a drunk, my father wasn’t around! My mom left us alone a lot and when she was there, she’d beat us up. I couldn’t wait to get out of there. (looks at Letitia) When I met you, you and your family became my family. And I love you guys. I know how much you wanted a baby, but I worried that I’d be like my mother. I didn’t want to disappoint you by not adopting, but I worried that if we had a kid, I’d also disappoint you by not being able to love it. intern: So you were sort of caught in the middle. Either way, you worried you’d disappoint Letitia. katrina: Right—I never thought about it that way, but yeah, I felt like I couldn’t win. intern: Can you tell Letitia a little bit more about your fears about being a mom? From what I know, I don’t think you have really talked about this? Letitia nods. katrina: Well, like I said, my childhood was terrible. My mother was either not there or was beating on us. I was the oldest, and I tried to protect my little brother and sister, which made it even worse for me. She’d take it out on me even more. letitia: Is that why I’ve never met her, why you won’t talk about her? katrina: My childhood was a nightmare. A living hell! All I learned was how to hate. I tried to protect my sister and brother, but I really failed at that. They got beat badly, too, I just got it more often. My little sister ended up in the hospital one time and when they asked me how it happened, I lied like my mother told me and said she’d fallen down some stairs. I think they thought my mother had abused her, but they couldn’t prove anything and I didn’t say anything. (Starts to cry.) Silence.

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intern: A lot of pain, Katrina. Letitia, I wonder how this is for you, hearing this. Maybe for the first time? letitia: It’s hard. I didn’t know how bad it was. intern: Don’t tell me, please—tell Katrina. letitia: (looking at Katrina). I’m so sorry. I feel guilty. Things were so different for me. I had wonderful parents. You’re so brave and strong, so loving and caring. intern: So, you feel guilty . . . letitia: (interrupts) I feel guilty for forcing you to have a baby when you didn’t want one. intern: You know, I’m not sure that Katrina didn’t want a child. I’m thinking that she just worried that she might end up being like her mother? She might end up hurting a baby? But she loves you, Letitia, and maybe she also hoped that she might be a good mom? That it wasn’t just doing it for you, it was something she wanted, too. She just wasn’t sure she had what it takes to be a good mom. That sounds like a lot of caring right there. Even before you all adopted Theo, Katrina was thinking about her adopted child’s well-being.

The social work student demonstrated much skill and insight as she deftly helped Letitia and Katrina understand one another. She reminded them to talk to one another and not to her, as Katrina shared her misgivings about having a baby. As their conversation proceeded, it became clear to both women that Katrina’s reluctance to adopt was not about not wanting a child—it was about worrying that she would not be a good mother. This realization was a turning point in Letitia’s and Katrina’s relationship and in their work with the intern. Each began to see the other’s viewpoint in a less accusatory and more productive way. As Letitia and Katrina begin to resolve a long-standing disagreement about adopting Theo—a disagreement that reflected their misunderstanding of one another—they were better able to manage and cope with Theo’s diagnosis and its implications.

TRAUMA-INFORMED PRACTICE ILLUSTRATIONS Jerry: The Pain of a Stigmatizing Life Transition and Past Trauma

Transitioning from the aspirations associated with being a mentally healthy person to a person with a mental illness is quite stressful. As this next example reveals, this transition is likely to be even more difficult when the individual also has a history of trauma. At age 18, Jerry had his first psychotic episode and was

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hospitalized for the first time. He responded well to medication and enlisted in the army. During his first tour of duty in Afghanistan, he suffered his second psychotic episode when an improvised explosive device blew up and killed several of his buddies. He went to a military hospital in Germany and was stabilized with a regimen of medications. The military psychiatrist determined that Jerry’s psychotic episode was due to what he had witnessed, and believed that Jerry was fit to return to duty once he became stabilized. Jerry returned to Afghanistan, where he remained for another nine months. He was discharged after a third psychotic episode that was precipitated by a raid on a suspected terrorist cell that he participated in, which had resulted in the death of several women and children. Since that time, Jerry, now 40, has been in and out of psychiatric wards run by the Department of Veterans Affairs. Most recently, after being hospitalized for five days in a psychiatric hospital, Jerry was discharged and ended up on living on the street. Since his discharge from the army, Jerry has been unable to hold a steady job and has become alienated from both family and friends. A student intern began working with Jerry when he became a client at the residential program for homeless veterans in which he was placed. Jerry had stopped taking his medications, explaining, “I just want to feel normal, like everyone else, no pills.” The following incident took place in the second week of Jerry’s participation in the program: Jerry slumps down in the chair across from the intern and begins to talk about how he ended up being homeless. jerry: I got tired of my mother telling me every day to get up, get up. She treated me like a kid. She would take my disability check. I paid her rent, and she gave me one, maybe two dollars to buy lottery tickets. She always wanted to control me. I think she just wanted my money. intern: That must have been really frustrating. jerry: (nodding) And that’s the way it has always been, well, since I got back from Afghanistan. Everyone wants to know why I like my fantasy world. Well, in my fantasy world, I don’t see dead bodies and body parts, and little babies dying! But whatever, it’s fine. intern: You say it’s fine, but I’m not sure you mean it. jerry: I’m 40 years old, and I’ve never had a woman in my life. I did have one woman that I bought. I don’t have a wife or children. I don’t work; I don’t have nothing and no one. intern: You want a life like most guys have. But you’ve seen so much, so much really awful stuff. No wonder you like to escape into your fantasies. jerry: (hanging his head and nodding) I want to be normal.

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intern: So, what does “normal” mean? jerry: I take the meds because everyone tells me I have to. But I don’t want to, at least not all the time. Sometimes I like to go to my fantasy world. Everyone tells me that those fantasies are not true. I know that, but sometimes I like to be there. But I’ll go along. I’ll take those pills. That’s what you all say I have to do. I feel like a guinea pig, by agreeing over the years to all these different medications. But I don’t want to be a guinea pig—I want to be normal. intern: You feel stuck—trapped between wanting to be without meds, but everyone around you feels that you need them. Jerry nods vigorously. intern: It seems like everyone thinks that if you just take the pills, you’ll forget about the horror. Jerry nods and becomes teary-eyed. intern: Have you ever talked about this—about what happened when you were in the Middle East? Jerry shakes his head no. intern: No wonder you like your fantasy world! jerry: The psychiatrist told me I should take that antipsychotic drug, Haloperidol. But I don’t think it’ll make any difference. intern: How would that be for you, if the medication changed you and you no longer had your fantasy world? jerry: Then I’d have the war shit in my head all the time. And I still wouldn’t have a woman or a life. I mean, how would my life be any different? I don’t think I could ever be like other people. I would be the same person, but without fantasies. intern: So, if you take medication, not much will change? You’re thinking you want more help than that. jerry: (shrugging his shoulders) All the doctors do is give you pills, but I still don’t have a life. But I always have the memories. intern: So the drugs will take away the fantasies, but they don’t fix anything else. Everyone wants to change you, but nobody has tried to help you have a life or deal with what you experienced. jerry: So, now you see where I am. All the shrinks and my family cared about was that I don’t act crazy. Not whether I am happy. intern: It seems like you feel that people who are supposed to help you have let you down, Didn’t try to understand what it’s been like for you. jerry: It’s not you. I don’t blame you. intern (smiling and leaning in): I don’t feel blamed, but I do feel upset that you didn’t get the help you needed and wanted. I want to help you. I want you to be able to live a life that is fulfilling for you, and I believe you can do this. But I

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think you are going to have to talk about what happened when you were in the army. You need to be able to put it to rest. You deserve to have your experiences heard and validated. They were horrific. Jerry relaxes in his chair and nods.

Jerry’s aspirations to be a “normal” adult were being thwarted by his mental illness and his traumatic war experiences. He movingly conveyed the depth of his pain, sorrow, and hopelessness, and, concomitantly, his fear of what would happen if he were symptom free. He was experiencing difficulty transitioning from living without a mental illness to living in recovery and dealing with his memories of war. The social worker tapped into Jerry’s grieving for all the things that he had missed out on his life. She also provided Jerry with muchneeded validation of the trauma that he endured while in the army, which was an important first step in helping him address and manage it. Valeria: Connecting Past Trauma with a Present Life Stressor

Valeria is a 25-year-old single woman of Guatemalan descent. She is a first-generation college graduate and has a career in graphic design. Valeria recently moved out of her parents’ home into her first apartment. She called the rape crisis center seeking counseling. A coworker whom she had become friends with raped her. She has tried to put this behind her, but in her first session with the worker, Helena, she claimed that things were getting worse. She acknowledged that she was not coping well with what had happened and felt isolated, depressed, and confused. She did not report the rape because she was embarrassed and ashamed, nor did she tell her parents or siblings. She worried that her family—all of whom are strict Catholics—would blame her, since they remain strongly opposed to any form of sex before marriage. In their first session, Valeria discussed feelings of guilt, self-blame, and distrust of her own instincts: “There must have been something that I did to invite the rape.” She also blamed herself for not being able to move on: “I should be able to get over it, stop thinking about it, and forget it.” Valeria saw this as a sign of weakness. In their second session, Valeria revealed, almost as an afterthought, that as a child she had been molested by a teacher—something that she had never disclosed to anyone. She brought this up because since the rape, she has been having flashbacks about the abuse in addition to the rape. Valeria talked “around” the rape and the sexual abuse, discussing relationships and trust in very general terms. The worker respected Valeria’s sense of space and timing, but she made

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a note of how little affect the client displayed as she discussed what happened to her. In the third session, Helena pointed out this pattern to Valeria. Valeria acknowledged this, saying, “It’s all too much. I don’t know where to start.” helena: So, how about if we start at the beginning, with where you are right now? What’s going on with you as you sit here? valeria: I feel like I have no control over what happens to me. I feel like bad shit’s going to keep happening, like it always has. helena: Because of what happened—the abuse and then the rape—it just feels like you have no control? valeria: I spend my time waiting for the next bad thing, like it’s right around the corner. helena: That’s scary . . . valeria: (interrupting) You bet it’s scary. I used to do things to prove to myself that I could take care of myself that no one could hurt me ever again. What a fucking joke! Got me raped, that’s what it did. I was such a dumbass. helena: So, when you say that, it sounds like you’re blaming yourself? valeria: Well, yeah. So, I’m trying to show myself how strong I am, and what happens? I let a guy rape me. helena: You “let” a guy rape you? You feel that you “let” it happen? valeria: Well . . . I guess. I mean, I should have known better, right? I don’t know. After what happened when I was in fifth grade, shouldn’t I have known? helena: So are you asking me that? Or yourself? Because I think you’re really asking yourself that question: first I “let” my teacher molest me, and then I “let” my coworker do the same thing. Does that sort of sum it up? valeria: Yeah. “Fool me once, shame on you. Fool me twice, shame on me,” right? helena: That’s a lot of blame on yourself, Valeria. From what I understand, a bunch of you went out for drinks after work, including the guy who raped you, and then he offered you a ride home. No reason to suspect anything, right? Valeria nods. helena: But then in the car, he forces himself on you. That’s your fault? valeria: I didn’t think I had too much to drink, but maybe I did. And anyway, after the teacher, I should have known better. I just should have known better! (Starts to cry) helena: It wasn’t your fault! Silence. helena: (softening her voice). Oops. Sorry . . . You see, I know that you didn’t cause the rape. It wasn’t something you did or didn’t do. And you didn’t cause the teacher to molest you. Again, it wasn’t something you did or didn’t do. But you

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don’t know that yet. I wish you did. I wish I could take that guilt right away for you. But I can’t. But together, we can help you with that. Help you accept that you were powerless, that it wasn’t your fault. But that will take time. Valeria cries softly. helena: I’m sorry . . . there’s a lot of pain, along with the guilt and the powerlessness.

In this practice excerpt, Valeria conveyed the intensity of her helplessness and guilt. Like many who have been exposed to trauma, especially in childhood, she has been victimized a second time. The feelings of powerlessness that resulted from the abuse placed her at risk of subsequent victimization. The worker perceptively reached for and empathized with Valeria’s fears: “Because of what happened . . . it just feels like you have no control.” Valeria “offered” Helena her deeply held belief that she was at fault, both for the rape and the abuse. Initially, Helena responded by providing Helena with a different interpretation: “That’s a lot of blame on yourself, Valeria . . .” This perspective was accurate, but it was offered well before Valeria could accept it. Helena recognized her miscue, after she tuned into Valeria’s silence. She then was able to sensitively affirm Valeria’s feelings of shame, guilt, and powerlessness. When she processed this case with her field instructor, Helena realized that her initial observation came from her desire to reassure her client. She quickly learned that comforting her client required her to have the courage to sit with Valeria and her pain, not try to jump over it. As this session continued, with Helena’s assistance, Valeria discussed in more detail the rape and her guilt: helena: You’re thinking you should have picked up some cues. Like what? valeria: Well, if I hadn’t taken him up on the offer to go out with the group. I feel partly responsible for doing that. Maybe he thought I was being forward, so I wouldn’t mind what happened. helena: Just because you accepted the invite doesn’t mean you wanted sex. valeria: Yeah, I guess I know that, but it makes me wonder. helena: A little piece of you thinks, “Maybe it wasn’t me,” but a bigger part, at least right now, can’t help but wonder what you did. I know it’s hard, but can you tell me more about what happened? valeria: After we had sex—well, after he . . . he . . . raped me—it’s hard for me to say that, to see it that way—I realized I was bleeding and I told him. He said, “Oh don’t worry, that happens all the time.” Well, I thought, it never happened to me before! Then he just left, and I couldn’t believe that he left me like that, as if nothing had gone wrong. It didn’t hit me that anything was really wrong

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until after he left and I sat and thought about it. I just tried to put it out of my mind at the time. helena: Listening to you, I find myself getting so angry! That he could be so dismissive. You were bleeding, and he blows that off. What was that like for you? valeria: I felt ashamed, embarrassed. And then like a fucking fool. I’m all alone, bleeding, and I’m thinking, what just happened? helena: So there you are, all alone. Trying to figure out what the hell happened . . . Did you tell anyone? valeria: Only one person knows. My best friend. She could tell something was wrong. But no one else. I’m too ashamed, too embarrassed. helena: How about the abuse—you didn’t tell anyone about that, either, right? You’ve been holding onto guilt and shame for a very long time. valeria: A really long time (becomes tearful). I’m so tired . . . I feel this takes up so much of my life—this is all I focus on. But talking about it with you does help. It not only helps me to hear myself say what I am feeling, but also to think about the incident and what happened, because much of it I have to put in the back of my mind. It helps to hear someone say that my feelings are normal. helena: Your feelings are normal—the confusion, the guilt, the shame, the sadness, and anger. Those feelings are all jumbled up right now, but talking them through will help you put the rape and the abuse in their place. A part of your past, not your present or future. valeria: I know that you do not blame me. You don’t think it was my fault. You believed my story and me. But I don’t know about other people. How can I know how to trust others; I do not trust my own instincts? helena: This is something that will take time, something that you can rebuild, and something we can work on together.

The worker repeatedly but gently corrected misinformation regarding Valeria’s contribution to the rape, but she also respected that Valeria was not yet ready to give up her sense of responsibility. Valeria began to develop a new perspective when she corrected herself and referred to what happened to her as rape, not sex. In an effective use of self, Helena shared her anger, as a way of validating feelings that Valeria had yet to acknowledge, but which would be an important part of her recovery. Valeria continued to struggle with assuming responsibility and self-blame, and in the third session, Helena helped her see how these feelings were connected to her sexual abuse. This is a challenging discussion, since the rape crisis agency that Helena works at places an eight-session limit on client services. Readers will see that Helena addressed the sexual abuse in order to enhance

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Valeria’s understanding of her reactions to the rape, but she did not probe too deeply. This session was close to the halfway point in their work. It would undermine Valeria’s already fragile coping abilities to encourage deep and explicit discussion of her sexual abuse. What was important was for Helena and Valeria to begin to plan for the next steps when their work ended: valeria: I am ashamed to talk about it [the rape]. I really do think at least to some degree that I brought this on myself, that I did not stand my ground with him. Just like when I was 12. Everyone loved Mr. Roberts [her teacher]. He was the cool teacher, and he gave me special attention. I thought I was cool. Then he started playing around with me when I stayed after school as a teacher’s helper. helena: So, back then, you also should have “stood your ground” with your teacher? A 12 year-old standing her ground against her teacher? valeria: Well, when you put it that way, I guess that’s not realistic. Silence. helena: Right, it’s not realistic but it still feels—in your gut—like you should have done something. valeria: This went on for the rest of the school year. I didn’t tell my mom or dad. I could have at least done that! helena: How about if we talk about that a bit: How come you didn’t say anything? You seem to think you could have, just like you think you could have done something about the rape. valeria: Well, my parents, they really are strict Catholics. I got my period, and I didn’t know what that was. I went to my mom, and she just handed me some of her sanitary napkins, said something I didn’t understand in Spanish, told me to be a good girl, and that was that. I had to find out from my girlfriend what it meant. helena: So, it sounds to me like you didn’t say anything to your parents because you got the message—rightly or wrongly—that they might blame you. Sex was something you just didn’t talk about. And then the cycle repeated itself years later. valeria: Wow, yeah. It’s hitting me like a ton of bricks. I let it happen once, and then I let it happen again! helena: Whoa, wait just a min . . . valeria: (interrupting). I know—let, I said let. IT happened once and then it happened again. helena: A big difference, right? (smiles) valeria: Wow, yes, a big difference.

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helena: I’m thinking that you are beginning to see the rape and the abuse in a different way. How the powerlessness and shame you felt about the abuse made you more vulnerable to someone else abusing you. That’s a huge step in the right direction! valeria: Yeah, it’s like a whole different way of seeing things. helena: When you start to give up feelings of blame, it’s likely that you are going to start to feel the anger—rage, really—that your teacher and your coworker took advantage of your naivete. And that will be a good thing, even though it will be scary. When survivors get angry at their abusers rather than themselves, they’re well on their way to overcoming what happened. We have five sessions after today. I’m thinking we can use our time to further explore all the mixed feelings you have about the abuse and the rape and help you develop ways to manage them. But as we get closer to the end of our work, we can look at next steps—where you go from here, if you want. valeria: Yeah, okay. I’m thinking I’m going to need more help with putting this behind me.

The worker’s support invited Valeria to examine her experience of sexual abuse and her feelings of self-blame that followed her into adulthood. It was not necessary for Valeria to provide many of the details of the abuse, which might have overwhelmed her coping capacities, in order to get in touch with her chronic feelings of guilt and shame. Helena continued to gently introduce to Valeria a new way of viewing her situation and respected that Valeria may hear what she has to say but was not yet ready to fully embrace it. In their remaining five sessions, Valeria and Helena did the following: • Continued to discuss Valeria’s feelings of shame, guilt, and anger • Helped Valeria see how her feelings, actions, and beliefs about the rape are connected to abuse • Identified Valeria’s feelings of loss and grief, which she had yet to be aware of • Discussed the steps that Valeria could take to tell her parents about what happened • Examined the pros and cons of reporting the rape to police • Identified next steps and possible resources (a group for rape survivors, ongoing counseling)

The human capacity to create and narrate a life story and to make a healing process of it is a compelling life force available to both client and practitioner in their joint work. Most of the practice vignettes in this chapter illustrate life stories of loneliness, despair, illness, or loss, as well as the search for meaning

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and coherence in these and other critical life stressors. With social work help, the narrators were better able to integrate difficult and traumatic events into a more positive, helpful life story. With the empathic, active listening of the social worker in each of these case examples, each person reinterpreted and reconstructed a life story that ultimately contained new conceptions of the self and relationships with others. As the storyteller was reconstructing it, each life story gained increased intelligibility, consistency, and continuity. The telling of the story, together with the listening, is a healing process. It is our human way of finding meaning in life events, of explaining our life experience to others and ourselves so that we can move on. The origin of the person’s troubling life issue may be located at any point in actual time over the life course. It may not be necessary to uncover memories of very early life to find a trauma that can explain the present life issue. It is enough to seek out its narrative point of origin in the remembered past—that is, the time and the circumstances under which it entered the life story.

Helping Individuals, Families, and

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Groups with Environmental Stressors

In this chapter, we examine how social workers can assist clients with stressors associated with their social and physical environments. Clients’ social networks, the organizations they encounter and the physical environment they inhabit can be important sources of support and resilience but also can create significant impediments to healthy and adaptive functioning.

THE SOCIAL ENVIRONMENT

Clients’ social environment exists on a continuum from the most intimate social relationships like families and friends to less personal but equally important interactions within neighborhoods, the workplace, and organizations and social institutions. Social Networks

Social networks are embedded in a cultural context and consist of family, relatives, friends, and neighbors, colleagues at work or school, and acquaintances.

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They can be envisioned as concentric circles that move outward from people with whom one has the most intense investment to the outermost social circle consisting of people who are known about or linked through significant others. As individuals age and develop over time, their social circles will expand and contract in response to changing circumstances. Social networks are important sources of support that buffer the impact of life stressors and promote resilience. They contribute and reinforce selfconcept and self-worth and shape views of self and others. Social networks meet the need for human relatedness and, in times of stress, may serve as informal helpers, eliminating the need for more formalized services. Social networks can provide four types of support: instrumental (goods or services); emotional (nurturance, empathy, and encouragement); informational (advice and feedback); and appraisal (information relevant to evaluation of self, others, and the environment). Knowing that networks are available for support results in individuals being less anxious and more confident when dealing with new stressors. Contemporary technologies like social media have had a profound influence on the forming, sustaining, reconstituting, and redrawing of social networks and their boundaries, creating a completely new source of support as well as stress (Lu & Hampton, 2017; Shensa, Sidani, Lin, Bowman, & Primack, 2016). Individuals can maintain easy contact with social networks regardless of geographic distance and time zones. Despite its potential benefits, social media has created stress in the form of cyberbullying, misinformation, and cyberstalking. Even when informal support systems may be available, some people are unable to use them. Individuals who perceive themselves as vulnerable or see others to be threats often exist within closed networks with weak connections. In chapter 8, we introduced Jerry, the veteran who experienced trauma associated with his war experiences in the Middle East and episodes of mental illness. In response to his negative treatment by others in his social network and the manifestations of his mental illness, Jerry ended up without a place to live, which led to his placement in a shelter for homeless veterans. Individuals’ social and cultural identities may undermine or promote help-seeking behavior from others in their social networks. In the same chapter, we presented Valeria, a young woman who was raped and a survivor of sexual abuse. Her strict religious background as a Catholic and her Guatemalan heritage intensified her feelings of guilt regarding her sexual abuse and assault and also hindered her willingness and ability to seek support from her parents, whom she assumed would blame her for what happened. Seeking help within one’s social network may threaten self-esteem and generate feelings of inferiority and failure. These feelings are intensified when

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individuals within one’s social network minimize, misunderstand, or ignore requests for help. This rejection can thwart future help-seeking efforts. Individuals who attribute their life stressors solely to personal shortcomings are more likely to feel threatened and to avoid seeking help from significant others. Others prefer privacy and anonymity, undermining their ability to seek help. Public admission of need can evoke shame and humiliation. A life stressor that conflicts with the social network’s cultural values and norms is yet another deterrent. For example, an individual confused about sexual identity may have difficulty talking with significant others because of their heterocentric or outright homophobic beliefs. Some social networks are too loosely connected that members may be unaware of another’s stress. Lacking meaningful contacts, members’ stress remains invisible. Some networks are unwilling to offer their resources to members even when stressors are readily apparent. When network resources are stretched too thin or also stressed, members may fear incurring additional pressures and burdens, while others may fear encouraging dependency. As discussed in chapters 2 and 3, when a natural disaster occurs, entire communities are affected, which undermines members’ efforts to support and help one another. Social networks have the potential to undermine one’s sense of identity and autonomy and thwart growth. Social networks can be a negative influence. A member of a drug-oriented or delinquent network may want to end her or his affiliation, but the network may exert a strong counterforce toward conformity, leading to severe stress and even possible danger. Pets can be an integral part of the social network (Sato, 2011). They provide companionship, safety, and security, fostering connections between individuals, providing owners with a sense of purpose, and combatting their loneliness (Chandler, Fernando, Barrio Minton, & Portrie-Bethke, 2015). Service animals provide support and practical assistance to the hearing impaired, blind, and individuals with medical and psychiatric problems. Social Welfare Organizations

In contemporary American society, a complex array of organizations respond to the health, education, and social welfare needs of individuals, families, groups, and communities. Social service organizations must maintain a balance among pressures exerted by legislative bodies; regulatory agencies; funding sources; community needs, values, and wishes; changing definitions of social need; new knowledge and technologies; and professional ideologies. These forces can work against the needs of the clients whom organizations are supposed to serve.

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Human service agencies often define their function in terms of helping clients change behaviors and may pay minimal attention to the role that the social environment plays. If social workers acquiesce to the organization’s definition of professional purpose, they may overlook environmental forces that contribute to or even explain clients’ difficulties. Readers will remember the following situations from previous chapters: • In a residential treatment facility, a child is placed on medication to control his behavior after staff complaints, even though the social worker advises against this. • Ms. Anderson is referred to a hospital social worker and has been described as “difficult” because she refused to take her medication. The worker understood that Ms. Anderson, an older African American woman, was grieving the loss of her leg due to diabetes and was intimidated by the hospital personnel, most of whom were white.

Organizations develop a division of labor that creates a structure of statuses and roles. How the social worker’s role is defined by the agency often constricts professional function and negatively affects service delivery, increasing stress for clients and providers. The pressure of large caseloads, time limits mandated by third-party payers, and shrinking resources create pronounced ethical dilemmas and increased stress for social workers in any setting. A hierarchy of statuses and roles may further constrict social work practice. Social workers often work in host settings—such as educational, medical, and forensic environments—in which decision-making is in the hands of professionals other than social workers. In these settings, the mission and purpose of the social work profession may be misunderstood, minimized, or devalued. The agency’s focus is likely to mirror the professional discipline that predominates, which undermines social workers’ ability to address the myriad forces that affect their clients’ lives. This can lead to disagreements about “who owns the client” and which professional view holds sway. Turf issues may surface even in organizations in which social workers predominate. For instance, a student was placed in a public department of social services in the child welfare unit. Prior to her internship, a dispute had surfaced between the foster care and child protective services workers regarding a shared  case. A child had been removed from his parents due to sexual abuse and placed in foster care. While in foster care, the child was sexually abused again by an older foster brother. The protective services workers blamed the foster care workers for “not doing their job,” but the foster care workers believed they had been unfairly blamed, since they were not involved in the older foster child’s placement.

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The disagreement led to the workers rearranging their office cubicles so that neither group had to face the other. The student described the atmosphere as “toxic.” The social work program agreed, and the student was placed elsewhere. Readers must consider how this environment affected the workers, and, in turn, their clients. An organizational climate that ignores the tensions and conflicts that surface among employees, discourages innovation and creative thinking, and devalues their contributions, feedback, and input undermines morale and promotes feelings of powerlessness. We must ask ourselves: how can workers empower clients if they themselves feel (and are) powerless? An organization develops structures, policies, and procedures to manage external and internal pressures, allocate responsibility, and coordinate tasks. It provides a chain of command through which decision-making occurs. Some authority structures are rigid and reward conformity, discourage innovation, and block horizontal and vertical communication. In other cases, authority structures may be too flexible, allowing practitioners to have a great deal of discretionary power with minimal accountability. Clients are then vulnerable to individual workers’ whims, prejudices, or narrow interpretations of service provisions. Organizations also develop policies and procedures that guide the way in which personnel interact with and treat clients. These guidelines should assure fair and equitable treatment for service users that is consistent with state, local, and federal laws and relevant accreditation and licensing standards. However, limited funding often leads to wait lists for services, and agencies often engage in creaming, whereby they take the clients who are most likely to benefit from services and least likely to create negative publicity for the agency. Consider the following example from an earlier edition of this book, which remains relevant today: Intake records from a family agency revealed that 75 percent of outreach clients had a significant wait for intake, while 90 percent of clients seeking services were seen quickly. A high proportion of the outreach clients were people of color, who were essentially denied service. The barriers to service created two pools of clients: “preferred” clients, who were able to wait, because their lives are not in crisis, and “unmotivated” clients, who were “resistant” to service. So, agency personnel blamed the clients rather than the intake procedures.1

In many organizations, policies and procedures proliferate and assume lives of their own, with a disregard of clients’ needs and the organization’s stated mission and goals. Some organizations use procedures and policies to ration or deny services. An overburdened social welfare organization may rely on long waits and

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complicated forms to discourage applicants, delay service, and block referrals. Other organizations may not formalize practices, which results in clients being subjected to workers’ idiosyncratic judgments. When procedures or policies are either underformalized or overformalized, they are potential stressors for clients. Informal structures also develop within organizations. These may support the organization’s responsiveness to client needs, or they may subvert it. An informal system may support scornful, punitive, or uncaring attitudes toward clients as displacements of feelings aroused by the authority structure of the agency itself. Consider the following: A student was placed in an inpatient psychiatric facility located in an impoverished, inner-city neighborhood. She expressed her discomfort with the way that staff— including her field instructor and other social workers—referred to clients. They laughed at and made fun of them, used offensive language to describe them, and generally viewed the clients as beyond help. The social work program validated the student’s concerns and determined that the environment in the hospital was not conducive to her learning.

The student was moved to another placement, but we again ask: what is it like for the patients, who are especially vulnerable, to receive “help” in a setting in which the norm is to demean and belittle them? Organizational boundaries also create stress for clients. Agency services may be inconveniently located for those they seek to serve, which inhibits client use because of inability to pay for transportation (or lack of it altogether), or fears associated with being in an unfamiliar geographic area. Agency gatekeepers such as receptionists and intake personnel may be unwelcoming and gruff. Many agencies employ armed guards, require visitors to go through metal detectors, or both. While often necessary, these requirements may be intimidating to clients. Because clients’ problems are often multidimensional, they often need services from more than one agency or organization. Interorganizational collaboration is often lacking, leading clients to “fall through the cracks,” become discouraged, and give up.

THE PHYSICAL ENVIRONMENT

Social work services tend to neglect the physical settings that clients inhabit, even though they have a significant impact on behavior and are often considerable sources of stress. The physical environment has long been viewed as a static

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backdrop for the biopsychosocial forces that were presumed to solely influence human behavior and development. Yet it is an important factor in the development and maintenance of relatedness, motivation, physical and mental health, and self-concept. Familiar places and structures provide comfort and reflect individual and group identity, and their loss can generate stress for individuals, families, groups, and communities. The life stressor of uprootedness is attributable in part to the sense of being torn from an identity base. For example, the prevailing view of homelessness has been that mental illness leads to this significant source of stress. Research actually suggests that the relationship between homelessness and mental illness is at minimum reciprocal (mental illness increases the risk of homelessness and homelessness exacerbates mental illness), and perhaps the inverse is true as well (homelessness leads to mental illness) (Anthony, Vincent, & Shin, 2018; Fitzpatrick, Myrstol, & Miller, 2015) To understand the complex exchanges that occur between people and physical settings, we distinguish between the built world and the natural world. There are three aspects of the built world (Altman, 1975). Personal space refers to an invisible spatial boundary that people maintain as a buffer against unwanted physical and social contact and to protect their privacy. Semifixed space refers to movable objects and their arrangement in space. Furniture, curtains, plants, pictures, colors, and lighting provide spatial meanings and cues. People often rely on environmental props (locks, signs, fences, and other elements) to regulate space in the social environment. Too much interaction can be experienced as crowding, while too little interaction might be experienced as social isolation. Both can be life stressors. Cultural factors influence peoples’ experience of physical space. In some cultures, intergenerational family living is the norm, with numerous family members sharing spaces such as bedrooms and baths. However, in most cultures, a certain degree of personal, private space is necessary for healthy growth and development. High-density communal living limits physical movement, undermines individuals’ experience of personal space, and demands behavioral coordination. Close proximity to others can promote cohesion and provide social support— for example, a single parent relies upon a neighbor to watch her children so she can go to work. But it also can lead to social overload and spatial constraints, which can be potent sources of stress for individuals, families, groups, and communities (Walton, 2018). Research demonstrates that overcrowding, particularly in poor communities, is associated with a host of mental and physical health problems, as well as increased interpersonal tension and conflict (Graif, Arcaya, & Roux, 2016; Henderson, Child, Moore, Moore, & Kaczynski, 2016).

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Fixed space, which refers to the structure and design of dwellings, can be another source of stress. For example, the layout of high-rise, low-income public housing violates cultural and psychological aspects of self-image and undermines residents’ sense of identity. The anonymity and alienation that tenants experience may explain the fact that vandalism and lack of upkeep of their apartments are common. In rural settings, substandard housing resulting from leaky roofs, noninsulated dwellings, and unstable structures contribute to poor health and unsafe living conditions. The lack of physical dwellings also contributes to stress. In many poor, innercity neighborhoods, there are no grocery stores. Residents have limited access to fresh fruits, vegetables, meats, and dairy products in these areas, a phenomenon known as food deserts (Smith, Miles-Richardson, Dill, & Archie-Booker, 2013). Residents must rely upon small convenience stores that sell mostly snacks and preprepared foods at inflated prices. In many of these neighborhoods, there are more liquor stores than there are grocery stores or other commercial ventures that promote health and well-being (Smith et al., 2013). Individuals living in rural areas experience similar challenges, particularly if they are poor. Needed services generally are located far away and accessible only by automobile, since public transportation often is nonexistent. Food deserts also are common in rural communities because of the distances that must be traveled to purchase groceries and fresh produce. Internet and cell connections may be unavailable, which contribute to isolation from social networks and an inability to access resources that exist in the built world (Santiago, Gutierrez, & Soska, 2016). The physical space of social welfare organizations also has implications for clients’ and their well-being. An organization’s space may be unattractive and inhospitable due to harsh lighting, uncomfortable and insufficient seating, and overly hot or cold waiting areas. Although adult clients often must bring children with them to appointments, many organizations lack play areas, further contributing to noise, confusion, and stress. These characteristics have been found to undermine clients’ willingness and motivation to seek help, as well as benefit from the help they receive (Goering, 2018). For example, a social work intern describes an agency serving poor, elderly clients as follows: The Senior Service Center (SSC) is located in the basement of a two-story building. A wire fence hidden by overgrown plants and weeds surrounds the entrance, making it hard to find. A small, hard-to-read sign is posted on the door bearing the initials “SSC.” When you enter, you climb down a few steps to reach the reception/ waiting room. The room is small, musty-smelling, and dimly lit. The receptionist’s

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desk is located in the middle of the room, and small wooden chairs are lined up along two walls. Most interviews are held in one office that is shared by 10 social workers. It contains a table and desk with two hard wooden chairs located next to the desk; two other chairs face the desk from across the room. There are no lamps or pictures. The agency’s drab features probably reinforce feelings of helplessness and despair in those served, and since the writing on signs is small and there are few directional signs, our elderly clients often get confused.

In institutional settings, the need for supervision and surveillance of clients often leads to consolidating residents into small, communal spaces. Arrangement of open and closed spaces in institutions, treatment cottages, and schools either invites or discourages adaptive behaviors in clients. The arrangement of furniture and other objects in residential settings promotes or discourages social interaction among the residents. Ward geography in any inpatient setting either supports or inhibits patients’ shifting needs for privacy or for socialization. A social work intern in a psychiatric facility reports: When I enter a patient’s room, I’m immediately uncomfortable because there were two people sharing such a small space. There weren’t really any personal objects because the hospital’s policy is to have nothing on the walls except a bulletin board to keep walls clean and without holes, to avoid repainting. Each board provides just a few feet for displaying cards and pictures. It’s so unhomelike. The dayroom is off by itself, far away from the nurses’ station, elevators, and bathroom. The chairs and sofas are around the perimeter of the room and are really uncomfortable. A television is at one end, and a small table piled with beat-up books and games is at the other. There are no tables for games to be played on. Residents rarely use the room. I thought to myself: “Why can’t this be arranged more like a living room?”

The answer to the student’s question is that the patients and staff, who have been in this environment for a long period of time, have come to view semifixed, movable spaces as fixed and immovable. People experience relatedness not only with others, but also with the natural world. The health and wellness promoting properties of the natural world and its restorative, healing, and spiritual forces have yet to be fully recognized. Yet wilderness programs, organized camping, and nature excursions are effectively used for clients such as disadvantaged youth and those with behavioral and emotional problems, and the therapeutic benefits of gardening have been recognized (Monroe, 2015). Inner-city, impoverished neighborhoods typically

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lack green spaces, while toxic emissions, pollution, and uncollected trash are common. These characteristics of the natural environment contribute to residents’ mental and physical health problems and undermine cohesiveness (Cox et al., 2017; Dzhambov, Tilov, Markevych, & Dimitrova, 2017). Toxic contamination threatens the health and life of people and their natural environments. Children’s exposure to lead has been found to reduce IQ, create reading deficits, lower class ranking, and lead to more high school dropouts. Rural communities often contend with polluted streams and rivers, as well as contaminated soil, as the result of runoff from coal and other industries. Sources of heat—including coal and gasoline—lead to household air pollution (Lobao, Zhou, Partridge, & Betz, 2016). Aging infrastructures in many poor, inner-city neighborhoods lead to poor water quality and sanitation and associated problems with rodents and trash. A recent example of the negative impact that contamination has on a community is the ongoing water crisis in Flint, Michigan. As a cost-saving measure, the city did not apply an additive to its water supply that would reduce corrosion of the aging lead water pipes. This led to significant contamination of the water and a myriad of health problems for residents of the largely impoverished city (Kruger et al., 2017).

SOCIAL WORK FUNCTION, MODALITIES, METHODS, AND SKILLS The Social Worker and the Environment

As discussed in chapter 8, helping clients manage life-transition stressors requires us to help them develop the skills needed to influence their social and physical environments. We also must direct our attention to the exchanges between clients and their social network. Mobilizing or strengthening supportive connections already in existence, finding new linkages and reestablishing old ones, enlisting the aid of natural helpers, and helping clients disengage from maladaptive affiliations improve transactions between clients and their social networks. With limited power and awareness of their rights, clients—particularly those from marginalized groups—become resigned to the unresponsiveness of organizations and other social systems. Our actions also must be directed toward assisting clients in accessing available resources, helping them advocate for themselves when feasible, and assuming this responsibility when necessary. The agencies that employ us are a source of power, and our profession is a source

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of status. Both can be used to improve clients’ environments and provide them with the leverage they require to meet their needs. Professional Methods and Skills

The skills presented in this chapter are used concurrently with efforts to address life-transition issues because environmental stressors often coincide with and reinforce life-transition ones. The professional methods and skills previously discussed—enabling, exploring, mobilizing, guiding, and facilitating—are used in tandem with those presented in this and subsequent chapters. All ebb and flow throughout work with our clients, as circumstances and client needs and interests dictate. When clients’ knowledge, experience, and physical, emotional, and cognitive abilities permit taking action on their own behalf in their environments, this becomes an important means of enhancing self-efficacy. If the social worker and client determine that client action is not feasible, they decide whether they should act together or if the worker should act alone, but continually involving the client in the process. The skills required to diminish stress and promote the environment’s responsiveness to clients’ needs range from those that involve minimal conflict to those that require workers—and at times clients—to become more forceful. Table 9.1 summarizes environmental stressors and the associated professional methods of addressing them.

Table 9.1 Sources of Environmental Stress and the Associated Professional Methods Environmental Stressors

Professional Methods

People are unwilling or unable to use available social or physical resources.

Enabling Exploring Mobilizing Guiding Facilitating

Client needs and the social/physical environment resources lack sufficient fit; communications and transactions are distorted.

Coordinating/connecting

Mediating The social environment is unwilling to provide available Advocating resources. Formal and/or informal social environment resources are unavailable.

Organizing Innovating

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Coordinating, Mediating, Advocating, Innovating, and Influencing

The set of skills that includes coordinating, mediating, advocating, innovating, and influencing is appropriate when clients lack information, are fearful, or are unable to use, respond to, or influence the natural and built worlds. In general, the worker might use guiding skills when clients have insufficient knowledge of the availability of resources and services, or if they require help in using them; or facilitating skills if clients are reluctant to use services. For example, an elderly client refused to apply for much-needed food stamps. The worker discovered that he was a proud individual who “had never asked for help with nothing,” until his present circumstances gave him no choice. To help this client hold on to his dignity, manage his feelings, and solve his life issues, the worker relied upon guiding and facilitating skills to help him apply for food stamps. A routine referral that did not take into account this client’s views of asking for help would fail. In many instances, however, the problem is not clients’ inability to use resources in the social environment, but distorted transactions between them and these resources. Clients also may lack, or want to disengage from, a social network, which requires that the social worker arrange an introduction to other existing networks or create new ones. Coordinating Skills

The worker uses coordinating skills to become more directly involved in clients’ social and physical environments when guiding and facilitating skills are insufficient to bring about needed changes. The first task is reaching an agreement with the client on a division of labor when dealing with environmental difficulties. Hopeless and vulnerable clients often expect social workers to do the work for them. However, we strive to transform passive acceptance of services in clients to active participation in them. A clear division of labor encourages clients’ involvement, is empowering, and minimizes discrepant expectations. Note the following scenarios: • The client, Tyrone, sought help from the social worker because he feared becoming homeless after being laid off from his job. Four years ago, he sustained an injury that left him disabled and unable to work. His current loss of employment—for which he was paid under the table—forced him to move out of his apartment and into his parents’ unfinished basement. His relationship with them was strained, and he knew they would not allow him to stay with them

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indefinitely. The worker informed Tyrone that he might be eligible for Social Security Disability Insurance (SSDI) because of his disability. They agreed that Tyrone would call the local Social Security office to inquire about possible benefits. The worker and the client determined that he could do this on his own with the correct contact information. • A developmentally challenged client, Richard, lived in supported housing in the community and complained to his social worker from adult disability services that there were mouse droppings and roaches in his apartment. His cognitive limitations hampered his ability to request corrective action from the housing agency. The worker offered to contact the agency on Richard’s behalf: “I’ll call the agency right now and let him know about the problem. That way you can hear what they say and also, if they have any questions, you’ll be right here to answer them.”

In the first example, had the worker stepped in and done the work for Tyrone, he would have undermined his client’s ability to manage his own life. The second example suggests that even when doing “for” a client, the social worker can engage the client in the process to promote empowerment. Since there often are power differences between clients and those from whom they need assistance, they may require our help in initiating connections. This requires that social workers obtain informed consent and involve the client as much as possible in decision-making. Barriers, both practical (like transportation and financial) and structural (like discrimination) also hamper clients’ efforts to connect with and use their social environment. In chapter 2, we discussed the concepts of social and psychological impotence. People need to experience some control over their lives, but because of economic and social marginalization, many do not. When people are thwarted in their efforts to achieve their aspirations, they too often give up. This results in clients’ unwillingness to assert themselves, which in turn reinforces their helplessness. We have an obligation to challenge this learned helplessness by mobilizing clients’ energy and personal resources. When we help clients identify small steps that they can take, this increases the likelihood of success. With each small step successfully taken, clients are empowered to take another small step. Social workers often believe that they have limited power to influence their clients’ social environments. However, from clients’ perspective, having a professional on their side provides support and hope. Lending the social worker’s professional status to the client includes sitting with a client in a waiting room, telephoning on a client’s behalf, and making appointments for a client. Our presence conveys to clients, and to those from whom they need help, that they are not alone; it reduces the possibility that their needs will be ignored or minimized.

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When Tyrone next saw his social worker, he complained that he “got the runaround” when he called Social Security. He was unable to get a straight answer but assumed that he was ineligible to apply for SSDI. The worker shared her anger at the way he was treated and suggested they strategize the next step. The worker’s anger encouraged Tyrone to express his own dissatisfaction with his treatment and to ask what else he could do. They decided that Tyrone would call the office again and ask to speak to a supervisor, with the worker present in the room. The worker would take over the conversation if Tyrone felt he needed that kind of help. To prepare Tyrone for this next step, the worker and client role-played the phone call. Mediating and Collaborating Skills

Our clients often require our assistance in bridging the gap between themselves and the resources they need in their network and organizational environments. The problem is not clients’ inability to use resources in the social environment, but distorted communication between them and their social networks, including the organizations intended to assist them. In mediating, the social worker helps clients connect with important social systems When we engage in mediation, we help individuals in clients’ social networks, including family members, friends, neighbors, and colleagues, as well as authority figures such as a landlord, law enforcement officer, creditor, or religious leader, to better understand clients’ needs and responses, or to secure concessions, access to rights, or entitlements on behalf of clients. Collaboration involves enlisting the participation of significant others in clients’ social networks in our change efforts. In chapter 8, we introduced readers to role-playing, specifying action tasks, and preparing and planning for task completion. The underlying assumption is that with preparation, clients have the capacity to interact more effectively and skillfully with the environment. In a case from chapter 8, a student worker was meeting with an inmate named Marvelle in advance of her parole board meeting. The worker helped Marvelle realize that her demeanor might undermine her chances at an early release. However, we often must do more than help clients understand themselves better—we must help them act more effectively on their own behalf. This involved role-plays in which Marvelle answered questions and presented her case to a “parole board member,” realistically enacted by the worker, who asked some tough questions: worker: So, Ms. Hawthorne, why should we consider letting you out of prison early? You were convicted of writing bad checks—a serious offense, one that this board doesn’t take lightly.

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marvelle: Yes, ma’am, I know, I was wrong to do this. I cheated people out of their money, and I am really sorry about that. Silence. marvelle: [Talking to the worker as her worker, not as a parole board member] I don’t know what to say next. I did what I did ’cuz I needed money for drugs. I’m ashamed and don’t really want to talk about that. worker: You’re not a bad person, Marvelle. You were heavy into your addiction. It’s not an excuse, but it is the reason, right? Marvelle nods. worker: So, say that. Let’s try again. [Adopting the role of parole board member] So, Ms. Hawthorne, you’ve been convicted of a serious crime. You wrote bad checks and people who trusted you were out a lot of money. Why should this board let you out early? marvelle: You are right, ma’am. I did something very wrong, and I deserved the sentence I got. I cheated some friends and my landlord out of money I owed them and that ain’t—isn’t—right. But I was a drug addict, ma’am. And when you’re a drug addict, you don’t care about nothing but them drugs. Now, I’m clean. Been clean ever since I got here. I started attending meetings even before I was convicted. Been attending meetings inside here. I’ve been clean for 6 years! worker [resuming her role as the social worker]: Great job! You aren’t asking anyone to feel sorry for you; you’re not excusing your actions. You’re just saying what you did and why you did it. And you’re letting them know that you’re clean.

The worker’s realistic portrayal of parole board members’ possible questions and reactions prepared Marvelle for the hearing, increasing the likelihood that she would be favorably reviewed. Role-plays also can help clients understand and take the perspective of another person, which helps them to be more successful in navigating their social environment. Take a look at this example: A student in the public defender’s office was preparing her client for his court appearance. She had informed him about what he could expect at the hearing, suggested what he should wear and who should accompany him to court, and what he should say. She suggested that they role-play the hearing. She took on the role of the judge, and in that role, she asked the client, “So what do you have to say for yourself? Why should I not find you guilty of assault?” The client had difficulty answering these questions, so the worker suggested they reverse roles: As the judge, what would he want to hear the defendant say? When placed in this role, the client

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was able to identify what he could say that might persuade the judge that he was turning his life around.

We often must be more directive in helping our clients interact more effectively with their environment by identifying—and then helping clients take—the next steps. The client, Anne Marie, introduced in chapter 8, sought help from a family service agency because she was depressed and lonely. She divulged to her worker, Felicia, that her brother and three of his friends had molested her as a child. With Felicia’s help, Anne Marie came to understand how her depression and loneliness were connected to her abuse. She did not trust men, nor did she think she was lovable or “worthy” of a “good” man’s attention. She engaged in brief sexual encounters that left her feeling more depressed and alone. Felicia needed to help Anne Marie do things differently, as well as addressing the sexual abuse. In the three months she would be working with Felicia, Anne Marie was unlikely to come to terms with her sexual abuse. Therefore, part of their work together would be to connect Anne Marie to resources to use when their time with one another ended. With the worker’s help, the client also began to behave differently. Anne Marie and Felicia identified the following steps that she could take, with Felicia’s help: • Anne Marie would work on developing a friendship with a man (since her previous relationships revolved solely around sex). She identified a male acquaintance whom she wanted to get to know better, which provided her with an opportunity to learn and practice new interpersonal skills with a man with no pressure. • Anne Marie would consider alternative means through which she could meet men (she tended to meet them on online sites that were known as places for individuals to “hook up”). Anne Marie was a dog lover and already participated in many dog-friendly events in her free time. She also was an avid hiker. These two interests provided her with opportunities to meet men in a different, potentially more positive context.

These tasks involved role-plays and behavioral rehearsals. For example, Anne Marie and the worker practiced how she would approach the acquaintance and invite him to get a cup of coffee with her. The initial steps that Felicia and Anne Marie identified involved homework assignments. The worker asked the client, for example, to look for a hiking club that she could join before their next meeting. Before meeting with others from whom our clients need assistance, social workers should engage in anticipatory empathy, as we discussed in chapter 6,

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consistent with how they approach their encounters with new clients. When we convey awareness of the perspective of others, we increase the likelihood that they will be more responsive to our clients’ requests. When the worker asked Marvelle where she would live if she were paroled, the client worried that she had “burned her bridges” with her mother. The worker and client agreed that the worker would approach her mother and inquire about the possibility of Marvelle living with her. The worker considered how she might be feeling about her daughter; when she reached the mother on the phone, the worker began by putting these possible feelings—of anger, guilt, or mistrust—into words, validating what Marvelle had put her mother through. This increased the likelihood that the mother could be become an ally in Marvelle’s quest for early release. Anticipatory empathy is also needed when we approach employees of organizations—including our own—from whom our clients need assistance. We need to acknowledge the stress associated with their work and annoyance about being “harassed” by us: “I know how terribly busy you are.” But we also appeal to self-interest: “I understand that Mrs. Smith [the worker’s client, a hospital patient] can be a real pain, but I think she’ll be less of a problem to you all [the nursing staff] if someone can explain to her in language she can understand how much longer she will be in the hospital. She seems really worried about that, and I think that’s why she gets so upset.” The social worker presents her request in a nonthreatening and empathic manner. The aim is to achieve positive rather than defensive or resentful responses. Our efforts on behalf of our clients demand the same disciplined and informed assessment of appropriate intervention strategies that we employ with our clients. We remind our students that some of their most important learning experiences will come through their missteps and mistakes. The following example is a clear reflection of this: Juanita was placed in an inpatient psychiatric facility and was assigned to work with Lucinda, a 40-year-old woman diagnosed with schizophrenia. Lucinda was hospitalized after she refused to take her medications, and she was found wandering half-naked in her neighborhood by local law enforcement. Lucinda had been placed in a locked ward for women out of concern for her personal safety since staff discovered her engaged in sexual intercourse with male patients. At a morning team meeting, Juanita learned that the previous evening, Lucinda had somehow been able to leave her ward and get into the men’s ward. She was discovered naked in a male patient’s room, with several men, engaged in

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sexual activity. Prior to the team meeting, it had been decided that Lucinda would lose all of her privileges as “punishment” for her actions. Juanita angrily confronted the nursing supervisor: “How come Lucinda gets punished when what must have happened is the night nurse fell asleep on the job? If he hadn’t fallen asleep, my patient wouldn’t have been able to get out of her unit and into the men’s’!” Juanita’s comments were met with silence, which further angered her, so she continued, “One of the reasons my patient is here is because she acts out sexually! She’s a risk to herself. How come nothing is happening to the men who were raping her? There were four men and her, and she’s the only one that got in trouble!” At this point, her field instructor apologized for Juanita’s actions and explained that she was a new, but very dedicated social work student. He respectfully suggested that the team talk calmly about what had happened and take into consideration the points that Juanita had raised.

Juanita’s desire to advocate for her client is understandable, but her way of going about it was likely to alienate both herself and Lucinda from the staff rather than connecting her and her client to them. Juanita had a skillful field instructor, who helped her explore and better manage her feelings and identify alternative ways of handling the situation. More important, her field instructor modeled an effective environmental intervention by doing the following: • Apologizing to the team for his student’s actions (but crediting her for the points that she made) • Empathizing with the “tough spot” that the nursing supervisor was in (she was having a hard time staffing the night shift and many of the nurses had to work overtime, which explained why the nurse on duty had fallen asleep)

The field instructor had a long-established relationship with the members of the team, which included the psychiatrist, psychologist, and nursing supervisor, and he was highly regarded by all. This previous goodwill, coupled with his skilled advocacy on behalf of the client, led the team to reconsider its decision regarding Lucinda. Our ability to influence resources in our clients’ social and organizational environment requires us to demonstrate our professional competence in a way that is respectful and does not lead to defensiveness. The importance of this skill is evident in the impact that Juanita’s field instructor’s intervention in the team meeting had on her client’s situation.

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Social workers develop and use informal contacts that provide them with a rich source of support and resources for themselves and their clients. Having lunch or coffee, sharing greetings and support with colleagues, and exchanging personal and professional favors all activate a norm of reciprocity and provide the basis for a favor from a colleague on behalf of clients. Social workers also create and use interorganizational networks to facilitate their and their clients’ ability to access organizational resources. Workers keep track of helpful (and unhelpful) personnel, as well as cultivating the norm of reciprocity. Resource files allow staff to pool their contacts and elevate the level of fit between client personal and organizational resources. Resource files developed by the agency or published centrally within the community are useful adjuncts, but formal files are no substitute for the professional exchange of favors or for building a professional reputation as a competent practitioner. Many of our students use the connections that they made with one another while in school as the foundation of their informal resource network once they have embarked upon their professional careers. Active, skillful involvement on committees, teams, consultations, conferences, staff meetings, task forces, and community meetings provide workers with the opportunity to develop and use formal organizational contacts. Staff members from other organizations are more likely to respond to a social worker with whom they have interacted and who has exhibited professionalism and conveyed respect, clarity, discipline, and good humor. Knowing and using organizational policies, procedures, and precedents is critical to helping clients more effectively navigate an organization. In a medical setting, social workers must be familiar with medical terminology. In psychiatric and mental health settings, practitioners must be knowledgeable about categories in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM V). In all settings, social workers must know the policy manual that guides the organization that they are dealing with. Being able to cite a specific policy or procedure useful to a client is most effective in securing entitlements. Because individuals and organizations may be slow to respond to our and our clients’ requests for assistance, we may need to engage in tactful perseverance. Being a “charming pain in the ass” is an art worth developing and is a useful collaborative intervention: “Hi, it’s Louise again, I’m sure you have been waiting all day for my call [said in a self-deprecating way]! I’m just calling again to see if you’ve been able to get me an answer about my client’s eligibility for SSDI?” Table 9.2 summarizes coordinating/connecting and collaborating/mediating skills.

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Table 9.2 Coordinating/Connecting and Collaborative/Mediating Skills • Coordinating/connecting skills: 0 Reach for informed consent. 0 Establish a division of labor. 0 Mobilize client’s energy and personal resources. 0 End the worker’s professional status to the client. • Collaborative/mediating skills: 0 Demonstrate professional competence. 0 Engage in anticipatory empathy. 0 Convey awareness of perspective of others. 0 Develop and use informal system contacts. 0 Create and use interorganizational resource networks. 0 Develop and use formal system contacts. 0 Know about and use organizational policies, procedures, and precedents. 0 Demonstrate tactful perseverance.

Persuasive and Assertive Skills

There will be times when we must take a more direct—and sometimes adversarial—approach in order to enhance environmental responsiveness to clients’ needs. This must reflect our professional assessment that such strategies are required to overcome resistance (Cuthbertson et al., 2016). Skills range from those that persuade others to those that require the worker to be more forceful. In all cases, social workers learn how to be assertive without being aggressive. The use of persuasion often begins with asserting client entitlement or need. The worker must be able to (1) objectively describe the concern, (2) acknowledge associated feelings, (3) specify the desired change or outcome, and (4) explicate any consequences. For example, the worker in an assisted living facility tactfully requests that the nursing assistant caring for her client be more patient: “I know how it is—Ms. Jones starts to yell and it’s hard to resist yelling back at her [1], but when you yell at her, she feels totally helpless and becomes even more unmanageable [2]. Maybe if you explain to her that if she only rings her buzzer once, you’ll do your best to come within five minutes and won’t yell at her [3]. I think this will make it easier on you and her, because she’ll be less argumentative [4].” Making a case may require us to argue on behalf of a client, including clearly defining the issue, specifying its boundaries, and proposing possible solutions. The social worker also tries to anticipate potential opposition to the proposal and the expected and unexpected consequences of adopting it. Throughout the process, we respect others’ opinions, but continue to express our position out of concern for the client and the good name and mission of the organization.

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Readers will remember Tyrone, who was attempting to determine whether he might be eligible to receive SSDI. He said he was getting the runaround from the staff member from Social Security with whom he had spoken, so he and the worker agreed that she would step in. The worker immediately asked to speak with a supervisor. When the supervisor came on the telephone, the worker introduced herself, explained why she was calling, and identified the steps that her client had already taken to get his questions answered. The worker pleasantly but firmly pointed out that she and her client did not expect a definitive answer, but she asserted that he was entitled to know whether it was worth his time to complete the lengthy application. She said she was asking the supervisor for her “expert” opinion, which the supervisor ultimately provided. In another example, the school social worker has been seeing Gabriel, a 15-year-old whose father was recently deported to his home country of Honduras. Gabriel had been a model student until he began to get into fights with peers and skip classes. The worker and client had been working on helping him manage the distress associated with his father’s deportation, but Gabriel continued to have outbursts in class. One of his teachers threatened Gabriel that he would report his family to the local Immigration and Customs Enforcement (ICE) office. (Gabriel was born in the United States, but his mother and older sister came to the United States illegally.) His worker met with the teacher, empathized with his frustration with Gabriel, and—with Gabriel’s permission—explained her client’s situation and assured him that they have been working on helping Gabriel more effectively manage his despair. She further explained in a nonconfrontational way that the teacher’s threat to report him to ICE only exacerbated his stress and reminded the teacher that Gabriel was a U.S. citizen, and that their school was located in a city that designated itself as a sanctuary one. In certain instances, social workers will need to put pressure on organizations and social networks to increase their responsiveness to clients’ needs by creating discomfort. In the case of individuals in a social network, the worker can appeal to their sense of obligation and right and wrong or remind them of legal considerations. Harking back to Marvelle’s story from earlier in the chapter, when the social worker contacted Marvelle’s mother, she empathized with her mistrust, but she also suggested that the mother probably still cared about her daughter and wanted to see her paroled and start a new life. Organizations and the individuals they employ often develop defenses that minimize, avoid, or deny clients’ life stressors. Before an organizational representative will bend an agency policy, make an exception, or stretch service

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boundaries, the social worker might have to precipitate discomfort with the status quo in that person. One of our students was placed in a homeless shelter for men. As a small nonprofit, the agency had strict limitations on how much discretionary money could be provided to clients. The student’s client had an aunt out of state who was willing to provide him with housing, but the client did not have the financial means to get to her home. The student made an appeal to the agency director: I know our policy discourages financial assistance to clients, but I spoke to John’s aunt in Virginia. She’s willing to have him stay with her, but she doesn’t have the money for the bus ticket, nor does he. I’m hoping you’ll consider letting us buy the ticket. That way, another bed will open up right away for another client. I’m worried that if we don’t do that, then John will be back out on the street when his 30-day stay here is up. There really isn’t any other option that I can find.

Workers may need to use the organizational hierarchy if they receive a negative response from an organizational representative. This may include a polite request for the name and phone number of the supervisor, as both the worker and client did in Tyrone’s case. The worker worked her way up the administrative hierarchy of the local social security office. When using the chain of command, the worker considers the potential consequences associated with going around instead of through the hierarchy. This might occur when an individual has expressly denied or dismissed the worker’s concerns. In other cases, the worker may skip this step altogether, choosing instead to appeal to an individual higher up in the organization. In either case, workers decide whether the individual should be informed that they intend to go to the next level of authority. This requires us to weigh the risks associated with giving the individual a “heads up” as a courtesy—which could result in that individual expressly forbidding us to initiate further action—or simply taking the next step and informing the individual at the next level of authority why we chose this route. We discuss in more depth using the chain of command to effect organizational change in chapter 15. Adversarial Skills

If mediating, asserting, and making the client’s case fail, the worker and client may need to consider more adversarial strategies. The Code of Ethics of the National Association of Social Workers requires us to consider these strategies when essential entitlements are denied or clients’ rights are curtailed. Before

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taking such actions, social workers evaluate the potential consequences to themselves and their clients and maintain a polite, respectful stance. Expressing outrage might make us feel better, but it could undermine our desired outcomes and increase the risk of retaliation for our clients and ourselves. In a previous example, the school social worker might have needed to imply further action had Gabriel’s teacher not backed off of his threat to contact ICE. The worker could have told him that she would contact the school principal and inform her that the teacher intended to violate school policy: “I do understand your frustration, but if you intend to contact ICE, you will leave me no choice but to let Ms. Johanson [the principal] know.” The threat to take further action cannot be empty. We must be prepared to follow through on any action we propose to take, if necessary. When we discussed the advantages of group work, we observed that there is power in numbers. Collective action can be more effective than individual action. Both clients and their workers gain strength and security from joining with others in similar circumstances. Mobilizing an organized response can diminish isolation and risk of reprisal and increase the chances of success. Collective action also is more likely to garner the attention of those we are trying to influence. This intervention can be a powerful way to help clients change an organization, as the following case illustration reveals: A student was facilitating a music and activity group for seniors at an assisted living facility and overheard a conversation between members about their embarrassment at being “caught” in their rooms being engaged in sexual activity. This happened to a married couple and to two other couples in romantic relationships. The student apologized for overhearing the conversation but asked if members wanted to talk further about the issue. They were eager to do so, and the student discovered a pattern whereby residents’ needs for sexual intimacy were being at best overlooked, and at worst minimized or ridiculed. The student helped members develop a strategy to meet with the agency’s executive director and request privacy and respect for their needs for intimacy, including sexual intimacy.

In chapter 14, we discuss the importance of this strategy when social workers help communities take collective action. We will face many situations in which our clients’ interests are ignored. We cannot challenge all of them because this will lead to burnout and reduce our overall effectiveness. Therefore, we must learn to choose our battles. Advocating for a patient diagnosed with schizophrenia who will become homeless unless the psychiatric hospital bends the rules and allows him to stay beyond the 30-day

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Table 9.3 Persuasive and Adversarial Skills • Persuasive skills: 0 Assert the client’s entitlement or need. 0 Argue on behalf of the client. 0 Create organizational discomfort. 0 Use organizational hierarchy. • Collaborative/mediating skills: 0 Imply further action. 0 Mobilize an organized response. 0 Choose our battles.

maximum is a battle that we may feel compelled to pursue. In contrast, you might not engage in a battle over a half-day school suspension. Table 9.3 summarizes adversarial and persuasive skills. Skills That Improve the Fit between Clients and the Built and Natural Worlds

In this section, we focus on improving the fit between clients’ needs and their built and natural environments, including an organization’s physical setting. Encouraging and Educating Clients to Use the Built and Natural Environments

For many clients, the physical environment can be overwhelming, inhospitable, and threatening. Vulnerable populations like individuals with mental illness, the aged, and children frequently lack the basic skills needed for moving through and using their built environments. Residents of many inner-city neighborhoods are fearful of leaving their homes because of gun violence and drug activity. Individuals who dwell in rural areas may live far away from others and the resources they need. The worker can help clients identify sources of renewal, support, and safety, such as public libraries, museums, parks, playgrounds, concerts, and recreational centers. For example, a student was placed in the local department of social services, in its family preservation program, designed to strengthen and support families at risk of losing their children. She discovered a reading program at the local library for parents and their children and was able to enroll her clients in the program. This provided parents with a comfortable environment that promoted bonding and positive interactions between them and their children. In another instance, an elderly client, Ethel, lived alone in a rural area of the county. A distant relative, who was Ethel’s sole source of support, asked the area’s

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office on aging for help, saying that she could no longer provide the assistance that she thought Ethel needed. After a home visit, the social worker linked Ethel to a number of services available to rural clients, such as free transportation to medical appointments, the grocery store, and the senior center; and in-home assistance with meal preparation and housekeeping. The worker also was able to supply Ethel with a cell phone for emergencies. The worker contacted a large home improvement store to inquire about the possibility of making a donation to repair her client’s leaky roof and install insulation against the cold. The store was willing to take care of these problems as a means of demonstrating its goodwill and community spirit. Using Animals to Provide Companionship and Supportive Relationships

A pet provides its human companion an opportunity to be nurturing and responsible. For example, Bryce was placed in a residential treatment facility for adolescents that was one of several located on a large suburban campus operated by a nonprofit organization. His facility had two “resident dogs,” which provided the human residents with comfort and companionship. Another student was placed in the assisted living program for aged clients located on the same campus. The students were able to implement a “pets-on-wheels” program, whereby the adolescents were trained to take dogs to the assisted living facility for weekly visits with its residents. Responding to Clients’ Spatial Needs in the Organization

We take clients’ spatial needs into account when we consider the overall exterior and interior appearance of our agency and workspace. Some clients require more spatial distance, while others might need less distance between themselves and their worker. The spatial arrangement of a worker’s office affects clients’ comfort and interaction. Wall art and plants are welcoming and convey receptiveness. Personal mementos, such as pictures of one’s family, convey a willingness to be personal and involved. By responding differently to clients’ various spatial needs, we enhance their willingness and ability to engage with us and promote well-being. In a family agency waiting room, a social work student noticed the lack of toys or reading matter for children and organized an effort to add inexpensive ones purchased from a local Goodwill store. In a public welfare setting, another student asked the staff to contribute magazines, children’s toys and books, and plants in order to make the waiting room more attractive and welcoming.

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The specific nature of our interactions with clients also must include spatial considerations. When working with children, the environment must be conducive to active play and provide necessary toys and games. When we work with a group, we must be sure that comfortable seating is available and distractions are minimal. When one of the coauthors was facilitating a parenting group, she quickly discovered the need to remove the distraction of members hearing their children being cared for in the next room. In working with a group for female adolescents, the coauthor assumed that chairs arranged in a circle would create an intimate atmosphere and facilitate interaction. The adolescents, however, were self-conscious about their short skirts. The small circle demanded too much physical and emotional intimacy with an unknown male professional. Addressing and Coordinating Spatial Access and Use in Clients’ Environments

When many individuals share a limited amount of room, stress can result from the interpersonal coordination required to manage restricted space. Helping individuals living communally to develop a schedule for morning use of a bathroom, evening use of a television, or planning meals may significantly mitigate interpersonal tensions and facilitate mutual support and assistance. Sometimes a worker-initiated discussion about privacy and clearer spatial agreements is sufficient. In other cases, the worker may suggest a simple environmental prop such as a lock on a bedroom, a room divider, or a screen. Table 9.4 summarizes the skills involved with influencing the physical environment. Trauma-Informed Considerations

The skills that we have identified that promote environmental responsiveness and enhance clients’ competence in their social environments are essential to trauma-informed practice. One of the challenges faced by adult survivors of trauma—particularly those who were abused in childhood—is deciding whether to disclose their experiences to others and to confront individuals who harmed

Table 9.4 Skills of Influencing the Physical Environment • Encourage and educate clients to use their natural and built environments. • Use animals to provide support and companionship. • Respond to clients’ spatial needs in the organization. • Address and coordinate spatial access and use in clients’ environments.

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or did not protect them. If trauma survivors do decide to disclose their experience or confront others, role-playing and identifying next steps enhance the likelihood that these encounters will be successful. Survivors of childhood trauma often assume that they will experience a sense of justice or closure if they confront perpetrators and those who enabled them and if these people take responsibility for their actions or inactions. We must help trauma survivors examine the reasons for their intended actions and realistically consider possible outcomes. Consider the following examples: • Victor sought help with posttraumatic stress symptoms associated with his combat experiences in the Middle East and his belief that two of his buddies were killed by friendly fire, although this had never been acknowledged by the military. Victor wanted the military to admit what happened and made numerous attempts to contact his former military commanders. One of his officers agreed to meet with Victor, which he assumed meant that this individual would validate his belief. The worker suggested that he and Victor discuss how the meeting might go and what he wanted to get out of it. They role-played various possibilities, one of which involved the former officer denying the existence of friendly fire. • Chana, a 24-year-old member of the orthodox Jewish community, was sexually abused by a neighbor as a child. She never disclosed this to her family because her parents were close friends with the perpetrator’s parents. Chana decided that she wanted to disclose her abuse to her parents. Through role-playing, Chana and the worker developed a strategy for her to talk to her parents about the abuse. Chana assumed that her parents would believe her, but she worried that they would have difficulty understanding her experience because sex was a taboo topic in their community. The worker offered to sit in on the meeting and help Chana explain her sexual abuse if necessary.

In chapter 2, we noted that trauma-informed care referred to the ways in which organizations respond to the unique needs of trauma survivors. The skills that we have identified, which increase an organization’s responsiveness to clients, are needed to promote the principles of safety, trust, choice, collaboration, and empowerment. Public waiting areas and offices should be comfortable, and offices must ensure privacy. A student was placed in a family service agency and questioned why there were “little boxes” outside each office. The field instructor explained that they were white noise machines that prevented office conversations from being overheard. Choice, collaboration, and empowerment are promoted when clients are provided an opportunity to have input into the services they receive. One of

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the coauthors led a group for men and women who were survivors of sexual abuse in an agency that provided a sexual abuse treatment program. In one group session, two of the men noted with embarrassment that they felt singled out when sitting in the waiting room with other clients. Parents tended to move their children away from them, suggesting the parents assumed that the men were perpetrators of sexual abuse. The group members believed that this was unfair and that the agency should do something about it, and they made their concerns known to the executive director. Although it was impossible to change the name of the program, the agency found an alternative space where group members were able to wait for the group, which eliminated the stigma the men felt.

PRACTICE ILLUSTRATIONS: HELPING CLIENTS WITH STRESSFUL ENVIRONMENTS

Strategies to alleviate the stress associated with clients’ interactions with their environment range from those that enhance clients’ competence to those that improve the social environment’s responsiveness. Next, we elaborate upon these strategies using practice examples. Social Network Stressors

Because the life-transitional challenges that clients face are often linked to social isolation, social workers mobilize, strengthen, or create connections between clients and significant others. “I Miss My Sister”: Reconnecting a Client to an Essential Lifeline

Maria, an 18-year-old, single, Hispanic, Catholic foster child, admitted herself to a psychiatric hospital after one of a series of suicide attempts. When Maria’s mother abandoned her at birth, she and her older sister lived with the maternal grandmother, but both were placed in foster homes when the grandmother could no longer care for them. Maria ran away from several foster homes, and at age 16, she was sent to a residential treatment center, where she made her first suicide attempt. In two meetings with Maria, the social work intern ascertained that she yearned for family and roots because she had lost contact with her older sister, who had enrolled in college. Maria felt isolated and unwanted. One day,

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Maria approached the social work intern in the hospital corridor, on the verge of crying. The social worker suggested that they sit on the couch and talk: intern: You look so sad right now, what’s bothering you? maria: (looking down) I miss my sister (tears falling down her cheeks). intern: I’m sorry . . . maria: I miss her for so long. I haven’t seen her since she went to college. intern: And it’s far away. maria: We both have no money. I get 60 dollars from the agency each month, but that’s not much. So I only see her on Christmas and holidays. I wish it were the holidays. intern: You seem to really feel the need to connect with her right now. maria: Yes (cries). We’re close. I can talk to her, though she don’t know about me trying to hurt myself or where I am. I don’t have no money to call her. intern: It’s gotta be really lonely not to be in contact with her when you need her. maria: Yes. But there’s no way to change it. I’ll just have to wait until Christmas. intern: Well, I think there is a way to talk to her. We could go into the staff office and call her right now, if you want. We also can work it out that you can Skype and e-mail her. maria: (brightens) Could we do that? intern: Sure. And perhaps you could invite your sister to visit you here. Maybe the hospital might help with the travel expenses. maria: I’m sure she’s busy with schoolwork and friends. intern: Let’s try, okay? maria: I’d love to talk to her now, but how would I explain being here? I’m not sure she’ll want to visit me here.

The intern and Maria agreed that their first aim was to help Maria reestablish contact with her sister. They developed a plan for her to explain her hospitalization to her sister. The intern successfully connected Maria to the only positive source of continuity in her life, and their subsequent reunion generated significant breakthroughs in her recovery. Maria became much more engaged in counseling and invested herself in developing new relationships on the ward. Addressing an Elderly Client’s Social Isolation: Enhancing Social Connections

Mrs. Bates is an 80-year-old widow living alone in a small house in a semirural area. Her two daughters live across the country. The older daughter, Margaret, and her husband, Paul, visit Mrs. Bates every two months. The younger daughter,

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Patrice, can afford to visit only once a year. Between visits, her daughters keep in touch with Mrs. Bates by telephone. Mrs. Bates does not have a computer or a cell phone. Margaret contacted the county office on aging, which provides comprehensive services to elderly clients, to convey her and her sister’s concerns about their mother’s well-being. Margaret said that Mrs. Bates’s cognitive functioning sharply deteriorated following a hospital stay a year earlier. The daughters were concerned about their mother living alone and so far from them. Mrs. Bates was assigned to a student worker, Anaya, who contacted Margaret and made an appointment to see her during her next trip to visit her mother. In the meantime, Anaya planned to visit Mrs. Bates and assess the situation so that she could determine her eligibility for the services. Initially, Mrs. Bates expressed uncertainty about meeting with the worker, but after several home visits, the client became more comfortable and disclosed her sadness and distress about her confusion and memory loss, but she maintained that her children provided her with all the help that she needed. Based upon what she learned from her client and the daughter, Anaya determined that the daughters, Margaret and Patrice, and Margaret’s husband, Paul, tried to manage Mrs. Bates’s life from a distance to compensate for their guilt. However, their micromanaging actually increased Mrs. Bates’s confusion and social isolation. Apart from her contacts with her daughters, Mrs. Bates had no other support system. Anaya helped Mrs. Bates’s family understand the need for their mother to regain control over her life. The intern commented: I met with Margaret and Paul before they saw Mrs. Bates, and we included Patrice using FaceTime. I acknowledged their concern and love, but suggested that at this point, their mother might need more assistance than they could provide. I also suggested that though they meant well, the more they tried to take care of their mother long distance, the less likely it was that she would avail herself of resources we could offer her. They agreed to work with me to help their mother accept our help. Margaret planned to visit her mother after our meeting, so I suggested she ask Mrs. Bates if I could attend their next visit to explain how we could help. Margaret agreed, and we decided that we also would have Patrice call in again. Mrs. Bates agreed to my coming during her next visit with Margaret and Patrice (who would be participating remotely). I explained the help we could offer: help with housekeeping, transportation to appointments, and activities at the agency like bingo and exercise, art, and computer classes. Mrs. Bates liked the idea of getting help with housekeeping and being able to use our transportation services, but she wasn’t sure about coming to our agency. She

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told us that she’s never used a computer, but her daughters pointed out that she was talking to Patrice by computer right then, since Margaret’s cell phone was a small computer. I pointed out that if she came to our agency, she could learn how to use one of our computers, which would allow her to see and talk to her daughters and her grandchildren. Mrs. Bates seemed to like this idea. As Margaret, Patrice, and I had previously discussed, Margaret then said that she would take her mother to the agency the following day, if she wanted. Mrs. Bates agreed, so I arranged to meet her and her daughter at the agency so I could show her around. Before Mrs. Bates got there, I asked a few other ladies if they would help me show Mrs. Bates around, to help her feel more comfortable. They agreed, so when she showed up with Margaret, we had a little greeting party. She seemed pleased to meet them, and they were great cheerleaders for our program. One of the things we made sure to do was show her how to use a computer, and then we Skyped with Patrice, who had children of her own, so Mrs. Bates could meet her grandchildren for the first time.

Mrs. Bates was initially reluctant to accept the much-needed services that Anaya’s agency offered, but the worker persisted, using the two sources of support her client had—her daughters. Her daughters provided Anaya with a powerful means of encouraging Mrs. Bates to give her and her agency a try. Anaya validated the daughters’ guilt and sense of responsibility and assisted them in seeing that these reactions were actually undermining their mother’s independence and contributing to her social isolation. The worker effectively used coordinating, facilitating, and mediating skills to introduce Mrs. Bates to her agency and services that would reinforce her independence, enhance her quality of life, and reduce her isolation. The worker demonstrated how to manage Mrs. Bates’s care without taking control of her life. She also was able to use social media to deepen Mrs. Bates’s connection to her family. Using Role-Play to Prepare Clients for Significant Interactions: Coming out as a Gay Man

In the previous chapter, we described a young gay man who decided to come out to his parents as gay. Grant and his worker, Beth, developed a plan for how he would go about setting up the meeting to disclose this, as well as what he would say: grant: So I’m worried that as soon as I e-mail my parents and tell them I want to meet, they’re going to know something is up and want me to tell them right away. I don’t want to do that.

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beth: Okay, so you need to figure out a way to arrange a meeting without them thinking something’s up? How do you usually communicate with them? Phone, visits, e-mail, texts? grant: Usually phone, once a week or so. But I do e-mail them, too. beth: Okay, I’m thinking that e-mail might be better. If you talk on the phone, it’s possible they might detect something in your tone of voice. Is that possible? Grant nods. beth: So, in an e-mail, you can say you want to get together, have a visit to catch up. I’m thinking you don’t want to make up a reason, because they might get angry that you misled them. So, just saying you want to get together might be best. You agree? grant: Yeah, that makes sense.

At this point, Beth and Grant discussed the specifics: where and when he wanted to meet his parents and what he would say in the meeting. Grant decided to send the e-mail to his parents that evening and ask for a meeting the following week, following his next appointment with Beth. In their next meeting, Beth and Grant discussed what he would say using role-play: beth: So, how do you think your parents might react? I know you don’t know, but what’s your best guess? Don’t tell me what you want them to say or do, because that won’t help you. What do you realistically think their reaction will be? grant: Well, I think my mom will cry and my dad will be pissed or won’t believe me. beth: Okay, so let’s start with that scenario. I know it’s a stretch, but let’s assume I’m both your mom and dad (smiles). How about you start? How would you start the conversation? grant: Well, I guess I would just ask how they are, what they’ve been up to, stuff like that. beth: Okay, so, talk to them—me—start the conversation. grant: Well, okay . . . Hey, mom, dad, how you’ve been (laughs nervously)? beth: I know this is weird, and I’m not your parents (smiles), but like we discussed, when we act this out, you’ll be better prepared, feel more confident. grant: Okay . . . Hi, mom, hi dad. Glad we could meet. It’s been a while. What’s new? For the next couple of minutes, Grant and Beth engage in small talk, as he would likely do with his parents. Beth then suggests that Grant broach the topic of him coming out. beth: I know it’s hard, but try putting your feelings, your experiences into words, why you’ve made the decision to come out now, what it means to you, for you.

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grant: Mom and Dad, I actually had a reason for wanting to meet with you today. Something I need to tell you. (Silence) So, for as long as I can remember, I’ve known I was different. I finally realized in high school I was gay. And I’ve hidden it from you, from our family since then. But I can’t do that anymore. I need to be honest about who I am. And I hope you can be okay with who I am because you are my parents, and I love you, and I hope you love me. beth: That was wonderful, Grant. That was from the heart. Now the hard part—let’s start with me acting out your parents’ reactions.

Beth then took on the role of each of Grant’s parents as he thought each of them would react. She also suggested that they also act out another scenario that reflected his view of the worst case, which he said would involve them disowning him and telling him they hated him. When they enacted this scenario, Beth assisted Grant with identifying how he might feel if this happened, and what he would do with those feelings. This included identifying friends he could call or visit to help him deal with the possible rejection. Beth considered telling Grant that he could call her if he needed to, but she realized that her job was to help Grant navigate this very stressful interaction with his parents and to identify social support that could be available to him for this situation and in the future. While his parents’ rejection would no doubt be devastating for Grant, his ability to cope with this was enhanced by having considered it as a possibility. Beth and Grant discussed the possibility of her mediating the meeting with his parents; Grant decided—and Beth agreed—that he could do this on his own with the preparation he had done. Organizational Stressors

In mediating exchanges between clients and organizations from which they require assistance, a critical area to assess is how much clients can do for themselves to increase their sense of competence and self-direction, as the following example illustrates. “I’m a Woman, and I Can Say NO!”

A social worker noted how her organization’s supposedly therapeutic environment reinforced the sense of helplessness among an inpatient group of people who had been hospitalized for depression. Hospital research staff regularly recruited patients for research protocols, but they did not provide patients with

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advance notice of when they would be tested, which was inconvenient and created anxiety for the group members. One of the purposes of the worker’s group was to help its members learn how to deal with the world outside the hospital, and the members increasingly invested themselves in discussions about assertiveness and self-empowerment. Here, the worker described a session in which members’ frustration and anxiety about the testing surfaced: mrs. king: (rushing into the room, out of breath and exasperated) I’m sorry I’m late—the research people asked me if I would be willing to take more tests, so I was upstairs—AGAIN! mrs. simmons: They really upset me. Last Friday—Good Friday—those research people asked me to do a few studies. They kept me over two hours. In the meantime, my friend Gloria came to take me to Good Friday Mass ’cuz I can’t get out of this place without a chaperone. She left after an hour, so I missed Mass. social worker: Ouch—is this testing mandatory? mrs. king: Well, it helps them with research that might help someone else someday. social worker: How is it actually helping you all? mrs. thomas: It isn’t helping me, it’s just easier to go along with it than put up a stink. social worker: Mrs. King, you feel the same way? Mrs. King nods yes. mrs. martin: Well, I don’t think we should have to go along with it! Social Worker: Okay—how could you respond differently to them? Mrs. Martin: Oh, gosh, I don’t know, but we shouldn’t let people test us if we don’t want to. mrs. frankos: I can’t even say “no” to my 2-year-old—how am I going to say “no” to a doctor? mrs. simmons: You too? Wait until they’re 15 and you still can’t refuse them! The members laugh. social worker: I think we have a theme song, ladies! What would it be? mrs. king: “I’m a Woman Who Can’t Say No!” Everyone laughs. social worker: So maybe we can work on changing the title to ‘I’m a Woman and I Can Say No!’ The members laugh. social worker: You know those assertive techniques we’ve been practicing? How about if we practice them now so you can learn to say no to the research staff when you aren’t interested or don’t want to participate in their study? The members nod and enthusiastically voice their agreement.

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The worker’s gentle manner and sense of humor encouraged members to share their experiences and prepare for their future encounters with research staff by rehearsing alternative responses that allowed them to refuse to participate. Building upon the assertiveness techniques that she had been helping members develop, the worker turned their attention to a problem that they all were experiencing: the arbitrary and unpredictable nature of the requests for their participation in the research and their inability to refuse. Their work to develop these skills was no longer abstract. “The Food Is Lousy”: Helping Elderly Residents Advocate for Better Food Service

In the following illustration, the student social worker described a nursing home group that she was facilitating and members’ concerns about the food: Mrs. Schwartz said she thought we should spend time talking about all the things that go wrong during meals. Mr. Ball agreed, saying that the food and service are lousy. Several other members nodded in agreement. I asked the residents to describe specifically what was bad about the food and service. Mrs. Schwartz said the napkins either arrived wet on the trays or were distributed at the end of the meal. I said I could understand how annoying this is. Mr. Silverman added that silverware is often missing from the trays, and by the time the missing pieces are brought, the food is cold. Mr. Phelps added they often get different food from what they ordered. Mrs. Schwartz agreed, saying she doesn’t know why they put things on the menu if they have no intention of giving them to the residents: “They pretend to give you a choice, but in the end, they give you whatever they damn please.” I acknowledged their frustration and said, “So, you have three specific complaints: napkins that are either wet or not given out until the meal is almost over; missing silverware; and the substitution of items that you’ve selected from the menu. I wonder if you have ideas about what we might do about these problems?” Mrs. Liebner asked, “Who could we speak to?” Mrs. Schwartz responded, “We could meet with Miss Jackson [the kitchen supervisor].” I asked the others what they thought. Mr. Goldstein said, “Talking to the supervisor won’t help.” Mr. Lazar agreed, “No one will listen to us anyway, so why bother?” I acknowledged their pessimism but suggested it was worth a try, and I would like to help them. We decided I would invite the supervisor to a meeting and reviewed what I would say to her. I then asked the residents how they should present their concerns to the supervisor. Mr. Silverman suggested we make a list and read off the items. Everyone

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agreed, and I asked who would begin the meeting and read the list. Mr. Goldstein said that as the group leader, I should. I responded that I felt it was important for the supervisor to hear directly from them. Mrs. Schwartz volunteered to start the meeting off. We role-played what she would say. Mr. Silverman and then others volunteered to offer specific examples of their experiences. We then considered how Miss Jackson might react and how to respond.

Before she approached the supervisor with the group’s request for a meeting, the social worker put herself into Miss Jackson’s shoes, engaged in anticipatory empathy, and imagining the likely impact of still more pressure on a busy, harassed staff member: I said to her, “The group members have been discussing their concerns about the food, and they feel it will be very helpful to have your input, so they have asked me to invite you to our next meeting.” Miss Jackson said she didn’t know if she could make it, explaining she has so many responsibilities. I acknowledged how busy she was, but added that the group members really feel she can be helpful to them, especially since they only had three very specific concerns. She asked me what their complaints were, and I told her. She smiled and shook her head. I said, “I imagine you’re really tired of hearing complaints, especially when you’re working so hard.” She responded, “You’re not kidding.” There was a pause, and she asked me what time the meeting would be. I told her, and she said she would come. I expressed my appreciation.

In mediating, the worker conveyed her understanding of the supervisor’s perspective and commiserated with her difficulties. Yet she persisted in stating the members’ need for her assistance. The worker continues: Miss Jackson entered the room [for the meeting], and as we agreed, I began by stating the general purpose of the meeting and suggested Mrs. Schwartz describe the first concern. Mrs. Schwartz explained the problem with the napkins. Miss Jackson explained that staff is sometimes rushed and water spills on the napkins, but she assured the group she would try to correct the problem. Group members said they would appreciate it. I asked if anyone else wanted to add anything. Mr. Silverman then asked about the pieces of silverware missing from the trays. Miss Jackson replied that she knew this was a problem and that she would have two extra sets of silverware sent up. Members agreed this was a good solution. Mr. Phelps said he would like to know why he gets Jell-O every day when he hates it and orders other desserts. Miss Jackson explained that when a dessert on the menu has to be changed, they substitute applesauce or Jell-O. Mr. Phelps said he prefers applesauce. Ms. Jackson

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made a note of his request. I asked why substitutions have to be made. She explained that when menus are made up, the department assumes a certain item will be on hand. When it isn’t, or they run out, substitutions are made. After discussing how residents could be given some choice, the meeting ended with Miss Jackson’s agreement to return in a month for a review of the results. The changes were immediately implemented and institutionalized.

The residents had continuously but ineffectively complained to the dietary aides, which only increased their sense of powerlessness. Meanwhile, the kitchen supervisor was vaguely aware of inefficiencies, but as she already felt overburdened and no one approached her directly, she did not address these problems. After mobilizing the group’s interest in taking action, the worker interceded by requesting that the supervisor meet with the residents. The worker was able to use the least amount of pressure needed to bring about the desired outcome. A Foster Child Confronts a Social Worker: Teaching and Helping Clients Use Self-Advocacy Skills

Until age 10, Sal, now 16 years old, had lived with his natural mother and her husband, both heroin addicts. Five years ago, because of severe neglect, the child welfare agency placed Sal and his brother Paul, now 11 years old, in a foster home, where they and the other children were subjected to extensive physical and sexual abuse by both foster parents. Sal and his brother were then placed in a residential treatment center, and six months ago, they were placed with new foster parents. The supervising foster care agency decided that Sal and his brother should visit with their mother in her social worker’s office. The mother stays on and off with her current boyfriend, Jerry, who had once beaten Sal for refusing to call him “Dad.” Jerry also frequently attends the sessions with the mother’s social worker, Mr. Briggs. While they waited for their mother’s late arrival at their last visit, the boys were bored and, according to Mr. Briggs, “acted up.” In response, Mr. Briggs threatened to send them “back to the treatment center.” According to the foster parents, when the boys returned home that evening, they were quite upset. When the student foster care worker spoke to Sal about this, he exclaimed, “I am never going to see either my mother or Mr. Briggs again! I finally live in a normal home, and I intend to keep things that way.” Sal asked the worker to intervene for him. However, she thought that he was capable of fulfilling this task himself, with her assistance:

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sal: Did you call Mr. Briggs? worker: Remember what we talked about before? You have the ability to call Mr. Briggs yourself. So, let’s help you figure out what you want to say to him. sal: I won’t go to see my mother tomorrow! My brother wants to go, but I won’t go with him anymore. He has to go alone, and that’s too bad. But I ain’t going! worker: What do you want to say to Mr. Briggs? Why you don’t want to go? sal: I hate him. I can’t believe a grown-up can behave like that—a man with schooling and a social worker, besides. He’s a fucking jerk. Because I didn’t act right in his office, he actually threatened to put me back in placement! Can you believe that shit? worker: I understand your anger and hurt, Sal. Let’s think about what you want to say to him so he can hear your complaints. sal: I’m going to say I hate him and I’m not going to see him or my mother ever again. worker: So you want to tell him how angry you are. Are there other things about the meetings you don’t like? sal: I can’t stand that Jerry is there. I want to be alone with my mother. He doesn’t belong in our family. And I don’t want to see Mr. Briggs there either. And I also can’t stand my mother being always high. worker: I think it is very important that you tell Mr. Briggs all the things bothering you—not that you hate him, because if you say that, he won’t hear what you really want to tell him. He needs to hear the specific things that you hate. He needs to know exactly how you are feeling. He needs to know how much his threat hurt and scared you. sal: Mr. Briggs should really call and say he is sorry. That would be the right thing to do. worker: I totally agree. But adults don’t always do the right thing and are not always aware when they do things wrong. sal: I hate his guts! That’s what I want to tell him. worker: I understand that, Sal. Do you remember how you stood up against your former foster father in court and told him in front of everybody how you felt about him and all that he had done to you? Do you remember how the judge came up to you afterwards and told you that she had never before seen so young a man do so well in court? sal: (after a long pause) Yeah, I did tell him what I thought of him in front of the whole courtroom full of people. worker: You did. And you were very brave to tell the whole story. And you did it in a way that everybody, including the foster father, heard you. I would like you to

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be brave again. You can tell me you hate Mr. Briggs, that you think he’s a jerk, ass, whatever. Say those things to me, any way you want to say them. sal: You’re right. I can call Mr. Briggs. I’ll tell him what my reactions are to everything that’s been going on.

Sal did call Mr. Briggs from the worker’s office and expressed his concerns. He added that because he was so upset, he would discontinue future visits. Mr. Briggs apologized for his threat and informed the worker that he would respect Sal’s wishes. Sal’s worker had the benefit of already knowing Mr. Briggs, so she was confident that he would be responsive to Sal. If this had not been the case, she would have had to prepare Mr. Briggs for the phone call and gain his support. There will be instances when we will be unable to pave the way for clients’ self-advocacy. In these cases, we owe it to our clients to prepare them for both possible and negative outcomes of their efforts. Empowering a Rape Victim: Helping a Client Advocate for Herself

While we want to encourage our clients to advocate for themselves, we must be prepared to take over this task if their efforts meet with resistance or when they are unable to take on this task due to their vulnerability. Maleeka was placed in a rape crisis center and worked with a college student who had been raped by a fellow student after an on-campus event. The client, Regina, sought help from a program in the community rather than the on-campus counseling center because she was afraid that word would get out about what happened to her. Regina expressed to Maleeka a desire to report the rape to campus police. Maleeka and Regina developed a plan for how the client would file her report. Regina told her story to a campus police officer and provided as much information as she could about the alleged perpetrator (she had met him before and knew him in passing). In their next session, Regina tearfully reported to the worker that while the campus police officer listened to her story, she felt dismissed and was not sure he believed her. She said the officer questioned whether the fact that she was drunk meant she did not “really remember” what happened, or perhaps she gave off mixed signals. Regina told the worker that she regretted reporting the rape, and now she was questioning the veracity of her memory. Maleeka was appalled at the client’s experience, admitting that she never considered that Regina would not be taken seriously. She described the conversation that followed her client’s revelation:

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maleeka: Oh my God, Regina, I am SOOOO sorry! I never imagined that the police officer wouldn’t believe you. I feel like I set you up. I should have considered this possibility, given the way our society is. Again, I am so sorry. Regina begins to cry. maleeka: I can’t imagine how humiliating this must have been for you. regina: It’s hard to find the words. I wanted to scream at him, yell at him, kick him, hit him. maleeka: You’re angry. Good for you. I want you to think about something. You have a lot of work to do, a lot of healing. But you also could—if you wanted to, and with my help—do something about how you were treated by campus police. You don’t have to do anything, and I’m not telling you to do anything. I just want you to know that you have options, if you want to do something about how you were treated. It’s your call. Silence. maleeka: So . . . what are you thinking (reaches out and puts her hand on Regina’s hand)? regina: I’m all confused. But I’m really pissed off! I don’t wanna see this happen to some other girl. maleeka: Of course you don’t, and like I said, you have every right to be enraged. And we can talk about things you and/or we might consider doing. But, again, I want you remember this is your call, whether you want to take this on when you’re just starting to deal with the rape. regina: What can I do? I think I want to hear my options.

Maleeka and Regina discussed possible actions, including reporting her concerns to the officer’s supervisor, filing a rape report with local law enforcement, and filing a complaint with her college’s dean of students. Maleeka also suggested that if Regina did not feel ready to take any of these actions herself, she—Maleeka—could do so on her behalf. Regina decided that she wanted to file a complaint with the officer’s superior, whom she knew was a woman, and was adamant that she would do so as soon as she left the session. Maleeka credited Regina for her courage but urged the client to consider the possible consequences: “So, I think going to the supervisor is a good idea, a good place to start. But I really want you to consider the possibility that the supervisor might be as bad as the officer. How about if we develop a plan for what you will do and say to the supervisor? And that has to include talking about what you would do if it doesn’t go well, if you get the same crap from her that you got from the officer.”

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Maleeka readily accepted responsibility for not preparing Regina for the possibility that her reported rape would not be taken seriously. Rather than becoming preoccupied with guilt—which she readily admitted to her classmates—she prepared the client for subsequent efforts that she might take to advocate on her own behalf. Maleeka acknowledged that she felt compelled to do something about a situation she considered extremely unjust, but she wisely understood that her responsibility was to help her client decide what she wanted to do—if anything. Maleeka also made it clear to her client that she was willing to become the client’s advocate if Regina desired this, but she provided the client with the opportunity to become an advocate for herself if she wished. Regina took the next step of setting up an appointment with the officer’s supervisor, but as Maleeka feared, this meeting did not go well. We will return to this case later in this chapter, when we discuss social workers’ efforts to enhance organizational responsiveness to clients’ needs. Improving the Fit between a Young Client and Her Teacher: The Importance of Mediation

There will be times when helping our clients develop self-advocacy skills is unlikely to change interactions with their social environments, either due to their vulnerability or the intransigent unresponsiveness of the individuals and systems that they need to rely upon. Mrs. Simpson has been teaching for more than 30 years in a large, urban elementary school. In many ways, she has become “burned out,” and this is reflected in her treatment of 9-year-old Jill. The teacher often singles out Jill in front of the class for misbehavior or unfinished work. The school social worker believes that Jill wants to fulfill Mrs. Simpson’s expectations of her, but she does so with complaints and negative comments and behaviors. Jill’s efforts to meet her teacher’s expectations are sabotaged because Mrs. Simpson only gives Jill attention when she was misbehaving. When the worker meets with Mrs. Simpson to discuss this, the teacher launches into another tirade against Jill. The worker reports: Mrs. Simpson said, “That kid drives me crazy . . . she draws attention to herself in the most inappropriate ways, constantly bothers people, and doesn’t do her work. Most of the kids in the class will not give her the time of day.” After listening and empathizing with Mrs. Simpson’s frustrations, I suggested the only way we can change Jill’s behavior is to identify and focus on some of her strengths. “Well, she is bright,” Mrs. Simpson responded, “and she reads well and does a good job explaining things in Friday class discussions.” I supported Mrs. Simpson’s assessment, noting I had

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seen similar qualities. I also commented on Jill’s creative imagination. I asked, “Can you think of any ways that we can use and channel Jill’s creativity and theatrics into something positive?” Mrs. Simpson was willing to try, but asked, “Meanwhile, what are we going to do about her behavior?” I replied, “How about if the three of us get together and talk about your frustrations with her in light of her special abilities and the good things Jill has to offer?” Mrs. Simpson agreed. I prepared her, and then Jill, for our three-way meeting. Mrs. Simpson began that meeting by berating Jill for her behavior and waving a note from the art appreciation teacher about Jill’s rudeness. She also complained about her lack of cooperation on a class outing. Jill was quiet, sad, and despondent, and I became discouraged. But I tried again: “You know, Jill, the other day Mrs. Simpson was telling me about some of the things she thinks are very special about you. Mrs. Simpson, I would appreciate your telling Jill what you told me.” Mrs. Simpson told Jill she was a talented girl and highlighted her special qualities. She also told Jill about her frustration when Jill doesn’t follow rules, how it disrupts the class and upsets her. Jill listened, and said she would try to behave better, but she doesn’t like Mrs. Simpson’s singling her out and yelling at her. I suggested they might try a private signal between them when Mrs. Simpson thinks Jill is going too far—it would be their “secret signal.” Both liked the idea. I also asked Mrs. Simpson if she could credit Jill more, in front of teachers and students. She agreed to try. We decided to meet in a week to evaluate the results.

The social worker’s determination to improve the fit between student and teacher was contingent on her ability to build on the strengths of both. Each needed to feel better about herself in order to feel better about the other. Jill was particularly vulnerable to scapegoating, so change had to be initiated by the more powerful person, the teacher. While each party contributed to and had a stake in the issue, the teacher had the power to reward and punish. The worker’s mediating changed the degree of reciprocity to a more favorable balance for Jill. Helping a Homeless Client to Obtain Needed Resources: Mediating on Behalf of Clients

Powerless and vulnerable clients often need workers to do “for” them to obtain essential services. This is necessary when conflict exists between a client and an organization, particularly when the client’s presence may exacerbate or otherwise increase the potential for negative outcomes. Mrs. James, a homeless client living with her 2-year-old daughter in a single-room-occupancy motel, had no food and no means of transportation.

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She asked her social worker from a child abuse prevention program to drive her and her daughter to the food pantry. The worker describes what happened when they got to the pantry: Mrs. James and I waited two hours until her number was called. I was sitting nearby and could see her engaged in heated discussion with Mrs. Folk, the coordinator. Mrs. James came out and said she was refused food. She said the coordinator was “nasty” and had previously banned her from the pantry. I asked how come, and she said, “I was with a man who got mean and swore at and cussed out Mrs. Folk.” Mrs. James felt that Mrs. Folk was blaming her for this. I suggested we figure out how Mrs. James could obtain some food, because it would be a shame to leave after such a long wait. I asked if Mrs. James wanted to talk to Mrs. Folk again, but she felt it would be of no use. I asked if it would help if I try to talk to her. Mrs. James told me to “go ahead.” I found Mrs. Folk, introduced myself, and said, “I know you are very busy, but would you have a few minutes to discuss Mrs. James’s problem?” She exclaimed, “She’s banned. I banned her three months ago!” I asked her to explain what happened. She reported that Mrs. James came in with Mr. Brown. They had stolen vouchers for a “Mr. Smith.” When she informed them that the real Mr. Smith had just picked up his food, they started cursing at her. I inquired whether both of them behaved this way. She replied that Mrs. James was as much involved as Mr. Brown. I said, “It sounds like clients can give you a hard time, and you’ve got a tough job.” She replied, “Yes. It really is. For no appreciation.” I asked if there was some way she might make an exception, because Mrs. James and her daughter had nothing whatsoever to eat. She repeated, “But she really was obnoxious. And structure is important here. If I let her get away with it, there will be chaos.” I responded, “I agree with you about how important structure and rules are. But is there some sort of compromise we can come to . . . some way which will keep your authority intact and allow Mrs. James and, more important, her daughter to have some food?” Mrs. Folk asked if Mrs. James was my client. I replied, “Yes. This is the first time she has asked for my help. I think if we work this out, she’ll start using me more for things going on in her life.” Mrs. Folk exclaimed, “Do you know why she asked you? She knew she was banned. She’s just using you!” I replied, “You may be right. But if you can think of a way out of this problem, I’d really appreciate it.” She still was unwilling to help, so I tried once again, “I can see you feel strongly about this. But I would really appreciate if you could find a way to give her some food . . .” Mrs. Folk threw up her hands and replied, “I’m not going to do this for her. I don’t care about her. I’m doing this for you because I see how

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much you care. She can get food here, but only if you come with her. Alone, she is still banned.” I thanked her and said that I thought her decision was fair.

Mrs. Folk and Mrs. James had become adversaries. The worker realized that Mrs. Folk needed some appreciation for her work. She accepted Mrs. Folk’s perceptions of reality but continued to assert Mrs. James’s and her daughter’s need for food. The worker remained calm, but she persisted. Because her relationship with Mrs. James was tenuous, she did not press her to examine her part in the problem, nor to participate in the negotiation. The worker sought to get her foot in the door with her client, and with skill and determination, she succeeded. Providing a Foster Child the Chance to Have Input into Her Placement Decision: Speaking on Behalf of a Client

When a disparity in power exists between clients and the service systems they need, the social worker might need to take an active and directive role. Latisha is a 16-year-old girl of Jamaican descent. She is in foster care and resides with her foster mother, her foster brother, and her biological 5-year-old sister. Latisha is in a ninth-grade special education class at the local high school. She has been in and out of foster care since she was 6 months old. At age 4, Latisha was placed with her maternal grandmother, who physically abused her by slamming her head against a wall, causing cognitive impairments and partial paralysis. Latisha’s father died one year ago, and her mother, Mrs. Yates, fell apart and began using drugs, resulting in Latisha being returned to foster care, where she has developed a loving relationship with her foster mother, Mrs. Simms. The social work student, Carla, interns at an agency that provides clinical services to foster children with developmental, behavioral, and mental health needs, as well as to their foster and biological families. She has been working with Latisha for the past six months. In the beginning sessions, the focus was on the loss of her father, her return to foster care, and her mother’s addiction. The mother’s caseworker at the Department of Family Services (DFS) contacted Carla and informed her that the agency planned to return the children to Mrs. Yates within the next two months. This news shocked the intern because Latisha verbalized to her a fear of her mother’s rage, and Carla understood that Mrs. Yates had not attended parenting training at the agency, which was a requirement for the return of her children. In addition, no one could confirm that Mrs. Yates had been clean or attending any drug program. The intern believed that the DFS caseworker had become allied with the mother and lost sight of the children’s needs.

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During subsequent sessions with Latisha, the intern reached for her feelings about returning home to her biological mother. Latisha vacillated between not wanting to hurt her mother’s feelings and not wanting to go home with her either. She really wanted to remain with her foster mother. Carla credited Latisha’s decision to take care of herself instead of taking care of everyone else. In preparing for Latisha’s service review meeting, Carla invited Latisha’s court-appointed advocate, Mrs. Trumbel, to join them for a session so Latisha could explain to her how she felt. During this meeting, Latisha was able to tell Mrs. Trumbel that she did not want to return home to her mother because of her irrational behavior. The service plan review meeting was scheduled for the following week at the DFS office. The DFS caseworker for Latisha’s mother wanted participation limited to her supervisor, the mother, Latisha, and Carla, but Carla insisted that Mrs. Trumbel, Mrs. Yates’s drug counselor, and the foster mother also be invited. The caseworker reluctantly agreed. On the day of the meeting, Carla met the foster mother in advance, helped her to think through what she wanted to say, and they briefly rehearsed how she would do this. On the way to the meeting, Latisha became increasingly frightened and requested that Carla speak first. Latisha wanted the intern to state that she loves her mother but is scared by her angry outbursts, and that she is comfortable and happy in her foster home. Carla agreed, stating that Latisha was brave to want these sentiments expressed, even though she feared her mother’s reactions. At the start of the meeting, Carla calmly introduced herself and explained that she had been providing individual services to Latisha on a weekly basis since September. The worker recorded what happened next: carla: Latisha was so nervous about today’s meeting that she told me she did not sleep last night. She asked me to speak on her behalf. [To Mrs. Yates]. She first wanted me to let you know that she loves you very much. Mrs. Yates smiles. carla: Latisha has given a great deal of thought about this, and decided that for now, she wants to continue to live with Mrs. Simms. This was a very hard decision for her, because she is worried about hurting your feelings. But she is also scared of your angry outbursts, and wants this to stop before she comes home. She also said that when she lived with you, she had too many responsibilities in taking care of her younger brother and sister and with housework and cooking—she couldn’t just be a kid. dfs caseworker: (interrupting) Mrs. Yates has been drug free for a year, so I told her that the children would be going home in the summer.

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Mrs. Yates’s drug counselor confirms that the mother had been clean for almost a year. carla: (to Mrs. Yates) Congratulations! This is a wonderful first step. I hope that you can work on dealing with your anger so you don’t scare your kids, and also get some help with parenting. (Turning to the DFS supervisor) I hope that the decision has not already been made? And that you will listen to what other people and Latisha herself have to say? The DFS supervisor expresses interest in hearing from them, but the DFS caseworker scowls. mrs. trumbel: As the court-appointed advocate, I believe that Latisha’s request has to be honored. I fully support the recommendation that before Latisha returns home, Mrs. Yates has to be able to manage her anger and allow Latisha to be a child. And she has to continue to get help with her addiction. carla: Mrs. Simms, I think you had something you wanted to say? mrs. simms: (appearing uncomfortable) I really worry about Mrs. Yates being able to manage her children. (to Mrs. Yates) I really hope you can get help with how to discipline before Latisha comes home. The DFS supervisor thanks all of the participants for their feedback and states that Latisha should remain with Mrs. Simms a while longer to allow her mother time to get help with her anger and support with parenting.

Carla skillfully represented Latisha, speaking forcefully on her behalf at a meeting attended by many professionals with differing points of view, as well as the biological parent. She “gave voice” to a child who could not represent herself. Taking on a Rape Victim’s Cause: The Need for Advocacy

At times, our clients’ efforts to advocate on their own behalf will be unsuccessful, and we must step in and use our status as professionals and our skills of professional persuasion to accomplish what they have been unable to do on their own. Readers will remember from earlier in this chapter that Regina, who had been treated dismissively when she filed her report of being raped with campus police, decided to advocate for herself by going to the supervisor of the campus police officer who dealt with her. Regina reported that Corporal Jansen, the supervisor, appeared sympathetic to her concerns, so she provided the supervisor with a detailed description of how the officer had treated her and what he had said to her. The supervisor then asked Regina to describe in detail what had happened to her during the rape, which resulted in her becoming extremely upset and embarrassed and crying in front of the corporal.

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Regina reported that the supervisor then told her that she was sorry, but she did not think that there was enough evidence to do anything. This ended the interview. Maleeka told her client that she was shocked, and she suggested that she would like to talk to her supervisor (Maleeka’s field instructor) to discuss what could be done next because, as a student, she was unsure. Maleeka also wondered if Regina would like her, and perhaps her supervisor, to get involved, since Regina’s interactions with campus police had been so stressful for her. Regina enthusiastically agreed. After talking with her field instructor, Ms. Ferguson, Maleeka arranged a meeting with Regina, her field instructor, and herself. Maleeka recounts this discussion: I told Regina what Ms. Ferguson and I had discussed, that unfortunately this sort of thing happened a lot. Colleges and universities were afraid of bad press, so they pushed stuff like this under the rug, that Regina shouldn’t feel bad that she didn’t get anywhere, because she had shown a lot of courage. None of us could have known how much the school wouldn’t want to pursue her allegations. My field instructor told her that she always had the option of going to the local police department and filing charges. She also told Regina that she could file a complaint with the chief of the campus police. Another option was to skip campus police and file a complaint with the dean of students. I also told Regina that I had looked up resources for her on campus. There was a women’s center, as well as an office that deals with sexual assault awareness. We thought that might be a good resource, too. We all decided that the next step was to go to the dean and the women’s center. Regina said she would be willing to talk to the dean, but only after we had approached her and believed she would be receptive to her allegations. We had time before our session was over, so I called the dean’s office, explained who I was to the person who answered the phone, and told her that I was calling on behalf of a client who was a student at the college. I wouldn’t give Regina’s name over the phone, but I told the woman that the client had made a report to campus police about a serious sexual offense committed by a fellow student, but that the officer, and then the officer’s supervisor, did not act on it. I asked that the dean of students contact my supervisor or me as soon as possible to discuss this. Our plan was to have an initial discussion over the phone and tell the dean what had happened to Regina, and then set up a meeting for her to meet with the dean, with us—or just me—attending. We decided we’d contact the women’s center once we knew how the dean would respond, to either get them on board to advocate for Regina if the dean dragged her heels, or to just be another source of support if the dean was willing to take action. The three of us also discussed what we would do if the dean wasn’t interested or wasn’t supportive. Regina was okay with us going above the dean’s head to the

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president of the college and would consider filing charges with the police. My supervisor had talked with our agency’s legal counsel, so we told her another option would be for her to talk to an attorney about the college’s unwillingness to do anything about her rape. There’s a pro bono legal service that would probably be interested in hearing her story. Luckily for Regina—for all of us, really—the dean called back the next day and was really concerned about what I told her. We scheduled a meeting, and when Regina and I met with her, the dean had already contacted the college’s women’s center to tell them she wanted them to work with her on Regina’s situation (she didn’t give them Regina’s name, just outlined the situation).

Even though Maleeka and her supervisor took over the role of advocating on Regina’s behalf, they involved her in each decision and action they intended to take. Their focus was twofold: to make sure that Regina’s rape was investigated and to address her college’s unwillingness to do anything about the report that she wished to file. Fortunately, the dean of students was receptive to and deeply concerned about Regina’s experience with campus police. Maleeka suspected that some of her concern might have reflected her worries about what would happen if Regina’s story got out. Whether this was true or not, though, the dean was willing to take action, and ultimately that is what mattered. The college’s formal policies, which provided students with a means of filing complaints to its campus police and offered sexual assault awareness and training to students, staff, and faculty was inconsistent with its actual practices. We want others to do the right thing, for the right reasons. But this will not always be the case, so we must be prepared to use whatever means of persuasion we have available to us. Regina—and her worker—were willing to move beyond collaborative strategies of interceding, persuading, and mediating to the adversarial strategies of pressure, challenge, and threat, but these more adversarial strategies ultimately proved to be unnecessary. Maleeka and her supervisor’s involvement lent weight to the cause of a vulnerable client whose attempts to advocate for herself were met with resistance. This helped to correct the unfavorable balance of power. Maleeka’s field placement ended before Regina’s complaint was resolved. Maleeka worked with Regina to refer her to another counselor in the community. During their last session, Regina expressed satisfaction to Maleeka that her school was taking her concerns seriously and was moving forward with an investigation of the campus police’s handling of her allegations. However, after this meeting, Maleeka was unable to receive any more information about the case for two reasons. First, Regina was no longer a client of her agency. Second, for privacy reasons, the college was unable to provide

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information to Maleeka’s field instructor about what it was doing to address Regina’s complaints, though it assured the field instructor that it was continuing with its investigation. Readers may be dismayed at the lack of resolution of this case. Maleeka certainly was frustrated at the lack of closure. Unfortunately, this is the reality, not only for students, but also for professional social workers. We often do not ultimately know how our clients’ lives turn out. Clients’ Built and Natural Worlds

Shelter is a basic human need. Yet a number of forces, including deinstitutionalization, loss of employment, eviction, displacement, intolerable conditions, natural disasters, gentrification, and the lack of affordable housing have led to an ever-increasing homeless population. When people lose their dwellings, they grieve their lost home and lost sense of community and all that is familiar to them (Gitterman & Knight, 2018). Familiarity with physical aspects of their environment, including one’s social connections (neighbors, community helpers, store clerks and owners, teachers, and school officials), provides a sense of belonging and personal identity. Helping a Client with Significant Cognitive and Emotional Impairments Secure Housing: A Major Challenge

A community agency employed social workers to reach out to cognitively and emotionally impaired homeless people who required a great deal of assistance with basic tasks associated with obtaining needed resources. Workers taught clients how to fill out forms, manage money, and take care of themselves, and they often made and accompanied clients to their appointments. Social workers had to be active, persistent, and directive in persuading agencies to be responsive to their clients’ unique needs and abilities, as the following example illustrates. Amin is 29 years old and of Sudanese descent. As a very young child, he witnessed the beating deaths of his grandparents by rebel troops in the Sudan. This experience prompted his parents to flee to the United States. He frequently ran away from home due to his parents’ abuse, only to have the police bring him back, in spite of his many bruises. When Amin was 12, his parents took him to a hospital, where he was determined to have suffered brain damage due to the many beatings about his head that his parents had inflicted. He was institutionalized and released at age 20. He has been homeless since his release, living in abandoned cars, automobile repair shops, and parks.

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Amin initially responded to the worker’s outreach because of his failing health. He was losing weight, not eating, drinking coffee and smoking cigarettes, and had deep sores on his feet and legs. Within several days, he arrived at the agency spitting up blood. The worker, Louise, accompanied him to the hospital and stayed while he was x-rayed. When she had to leave for another appointment, Amin left too. From then on, Louise escorted Amin to his various appointments and remained with him throughout. The mutually agreed-on goal was placement in an adult group residence. A psychiatrist determined that Amin possessed borderline intellectual functioning and struggled with posttraumatic stress associated with his childhood experiences. Amin was impulsive, unpredictable, self-harming, and subject to angry outbursts. He frequently yelled at Louise and stormed out of the office, only to return later for his next appointment. Because Amin frequently engaged in offensive behavior, he was socially and emotionally isolated. Louise recognized that Amin’s behaviors reflected the only way he knew how to cope with his past traumas and the harshness of his current situation. The social worker helped Amin with his health issues and medical care, including applying for entitlements, and they began the search for appropriate housing. In the past, Amin had applied for Supplemental Security Income (SSI), but he never filled out the forms correctly. A Social Security employee with whom Louise had previously worked agreed to meet with Amin in the social worker’s office. Louise described this encounter: Amin assumed his usual position in the far corner of my office, wedged between a table and file cabinets. I introduced him to Bill and reminded him that Bill was here to help him with SSI. Bill gently asked Amin some questions, filled out some forms for him, and Amin agreed to have the first check mailed to the agency and subsequent ones to a bank after we opened an account for him.

This session was successful because Louise structured the situation, created norms of informality, talked to Amin respectfully, and mediated the exchanges. Louise also was able to arrange with another social worker she knew for Amin to visit an adult group home. Jackie, the social worker, agreed to show Amin around and answer his questions. Louise describes this experience: On the way to the house, Amin was quiet and tense. I reassured him that this was only a first meeting; he didn’t have to make a decision, and if he doesn’t like the place, we’ll visit others. On arrival, Amin announced that he isn’t going in—he’d sit

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in the car. I sensed his growing panic and resentment, but I remained calm and told Amin that I would really appreciate his just looking at the place. He didn’t have to talk, but if he chose not to come in, I would go inside and then describe to him what I saw. Amin followed me in. Jackie gave us a tour, and Amin was introduced to several other residents. After the tour, we sat down to talk. Amin announced that it would take him a year to make up his mind, and he would get back to me with his decision, reflecting his pattern of rejecting before being rejected. Jackie and I encouraged him to think about it. Amin and I thanked her, and we left. He then informed me he wanted to live there. He said he was quiet because he doesn’t know “those” people, and he didn’t feel comfortable trusting them. I validated this.

Louise avoided a potential power struggle by leaving to Amin the decision about entering the residence. Louise worked at involving him, supported his decision-making, and respected his style and manner of coping, thereby increasing his self-esteem and self-direction. At their next meeting, they discussed the residence: amin: I’ve got to think about what I want to do. louise: Well, Century House [the facility] is one possibility, and if that’s where you want to live, there are certain things we need to work on in order for you to get in. Remember, if it’s not what you want, then we’ll work on other possibilities. amin: It’s better than living in the garage or on the street. I feel like just running away. louise: I understand your feeling frustrated, but running away isn’t going to make those feelings go away. amin: I gotta have people to talk to. I can’t keep living lonely like this. louise: I know. You’re scared to take the next step, but you also can’t keep living like you are living. So maybe if you go to Century House, since it is a place with lots of others, you’d be able to make some friends? amin: Well, maybe I could live a happy life. Louise pats Amin’s knee. louise: So, maybe Century House will help you have a life? Remember—you’ll have to have some tests (last time Louise mentioned this, Amin exploded, so she braced herself) amin: Forget it! louise: But it’s the only way we can get you into Century House. amin: Forget it!

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louise: I know this is scary, but since it has to be done, what can we do to make it easier? amin: No needles! I am afraid of needles. I don’t like to get pricked. louise: I don’t blame you, and I don’t like it either. But they’re going to need to test your blood. How about if I stay with you? amin: If you stay with me, then I’ll stay, but if you walk away, then I’m going to leave too. louise: Let’s shake—we just made a deal.

Louise slowly and patiently helped Amin connect to the various systems that he needed to obtain housing, since he lacked the skills and trust to negotiate these environmental resources on his own. With Louise’s presence, persistence, support and demands, Amin gained confidence in his own abilities. Each success motivated Amin to risk and trust, experiencing increased feelings of self-efficacy. When Louise received Amin’s first Social Security check, they opened his savings account and figured out a weekly budget. With Louise present, Amin began literacy classes at the library. He also began to participate in her agency’s support group, trips, and educational seminars. Five months later, he moved into Century House. “Let’s Take a Field Trip!”: Using Community Outings to Help Clients Learn to Navigate Their Social World

Navigating the built world can be challenging for many clients, particularly the elderly and those with mental illness and/or physical and developmental disabilities. Basic skills and activities that most of us take for granted, like purchasing groceries, using a library or public transportation, and going to a movie, may be confusing, and therefore out of reach, for these clients even if they have benefits to rely on. Developing comfort in and the ability to use services in the community enhances clients’ sense of competence and mastery and provides them with opportunities for social interaction and recreation. Kaitlyn was placed in a day program for adults with developmental challenges that provided job and life skills training and on-site employment. Most clients lived with their parents, while others lived—or were being prepared to live—semi-independently. Kaitlyn observed that her clients were being taught skills at her agency but were not provided an opportunity to practice those skills in the real world. The student formed a community field trip group, which went somewhere together once a week for six weeks. The six destinations reflected those that Kaitlyn believed would be most helpful and easiest to navigate, and that also had been suggested by members

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themselves: a fast food restaurant, a grocery store, a dollar store, the public library, a trip on public transportation, and a movie theater. Kaitlyn understood that it was important for members to experience success in each venture. She assumed that with each successful outing, members would approach the next one with more confidence. Prior to each outing, members met with Kaitlyn to discuss their upcoming “field trip.” In this preparatory session, she provided members with information about where they would be going, how to interact with others they would meet such as cashiers or salespeople, and answered their questions and addressed their fears. Kaitlyn’s group became more than just educational. As members became comfortable, they provided support and encouragement to one another. This, coupled with the actual outings, lessened the members’ fears and enhanced their willingness to venture into their local community. The group was so successful, and members were so satisfied, that the agency decided to make this intervention an ongoing service offering. Helping a Traumatized Client: Connecting a Child to a Pet

Angel, age 8, was placed in residential care for emotionally and behaviorally challenged children. He had been violently abused by his father and witnessed the sadistic abuse of his mother and siblings as well. After Angel was forced to hold a knife to his mother while his father raped her, he “snapped” at school, breaking furniture and windows. His father was convicted of assault and sentenced to seven years in prison. Angel entered court-ordered placement with minimal language, social, and learning skills. He was withdrawn and fearful of others and suffered frequent nightmares about his father escaping and killing his mother and him. But his mother did remain a stable force in his life, visiting every weekend and calling him frequently. The worker, Brett, noticed that Angel was gentle with a childcare worker’s dog. When the dog had puppies, Brett suggested to the administrator and the childcare worker that if Angel were willing to assume responsibility for a puppy, the center should consider taking one. After receiving permission, he discussed the idea with Angel, who responded with enthusiasm. Angel named the puppy Beauty and took wonderful care of her. Brett was able to draw parallels between Beauty’s and Angel’s experiences during their sessions. angel: (talking to Beauty) Oh, Beauty, don’t do that (the puppy is chewing on the worker’s calendar). I have to watch you every minute. You need me to take care of you and protect you. You are so little; you don’t know things.

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brett: She doesn’t know? angel: No. She’s just a little puppy. Little puppies don’t know. brett: So, I shouldn’t be upset with her because she is chewing on my calendar (smiling)? angel: She doesn’t know she’s not supposed to because she’s so little. brett: Uh-oh. She just began to chew on a report I was preparing. angel: Important? brett: Yes, but I should have put it away because I am the big person and Beauty is the little puppy; she doesn’t understand. angel: I’m the big person who will protect Beauty. No one is going to hurt her ’cuz I’m here. brett: Beauty has a big person to protect and care for her. Did Angel have big people to protect and take care of him? angel: My Mom yes. My Dad no! I told you my Dad is really bad. brett: I remember the things you told me. angel: Yes, like when he hurt my mother and I held a knife on her. brett: Remember how I’m always reminding you it wasn’t your fault? angel: But I did it. brett: Yes, but you were little and your dad was bigger and stronger. You were like Beauty. Beauty is little and doesn’t know what she is doing; she needs us to help her learn things. You were little and scared, and had to do what your father said. He would have hurt you otherwise. angel: He would have killed me if I didn’t. brett: Right, your father was very big, and he knew what he was doing was wrong. angel: Yes, he should have kept me safe. brett: Exactly! Like you are keeping Beauty safe. angel: Oh, Beauty, I won’t let anyone hurt you. You’re just a little baby puppy who doesn’t know.

With Beauty’s help and Brett’s skilled use of metaphor, Angel began to understand that as a small child, he was unable to protect his mother from his father’s violence. He began to understand that he, like his mother, was a victim of his father in the rape incident. As he felt more protected and less guilty, Angel revealed more stories of abuse, usually with Beauty in his lap. He told them with increasing anger and decreasing self-blame. Taking care of Beauty made Angel feel responsible and valued. Brett’s understanding of the healing power of pets helped Angel begin the transition from victim to survivor.

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Using the Natural World to Promote Mutual Aid: Creating a Landscaping Group for Individuals with Chronic Mental Illness

Marquis was placed in a psychiatric hospital’s transitional housing unit and was tasked with developing a group. Because the patients were being prepared to move to communal living, he and his field instructor believed that a group that promoted social interaction would be helpful. Marquis noted that patients rarely interacted with one another and spent much of the day staring at the television in the day room. The only time they seemed to engage with one another was when they congregated outside to smoke. Marquis also noted that sometimes the patients talked among themselves and lingered outside before going back indoors. He proposed that he facilitate a group that in some way incorporated the outdoors (but not the smoking!). Ultimately, he decided to start a group centered on caring for the gardens that surrounded the patients’ residence, since he had observed several patients picking weeds and others had expressed interest in being outdoors more frequently. The group was open to any resident who expressed an interest, and in addition, specific patients were encouraged to attend to enhance their readiness for their transition into the community. Marquis ended up with a core group of six members, with other patients joining in when they chose. He ran the group once per week throughout his yearlong internship, so members had a range of gardening experiences through the fall, winter, and spring months. During the winter, and when the weather was bad, the group met indoors and focused on enhancing members’ knowledge of plants, trees, flowers, and gardening. Marquis discovered very quickly the unique benefits of this group. Providing patients with the opportunity to experience and participate in their natural world allowed them to connect with one another in a relaxed and authentic way. It also provided them with skills and interests that could be cultivated and directed toward hobbies or even employment in the future. Marquis also observed that any time the group met outdoors, the members seemed happy and at ease; the grounds around their building were quite pretty and a far cry from the inside, where there was harsh fluorescent lighting, drab, gray, cinderblock walls, and tattered sofas and chairs. In chapter 11, we return to group work and the skills that workers need to foster mutual aid and address problematic dynamics that have the potential to undermine it. First, however, in the next chapter, we turn our attention to helping families in distress.

Helping Family Members with

TEN

Maladaptive Communication and Relationship Patterns

All families face life transitions, traumatic events, and environmental pressures. Many families manage the inner and outer demands of these life issues using coping mechanisms already available to them, or else they develop new ones in response to stress. For other families, though, the demands from internal and external stressors may go unrecognized, leading to increased tension and distress. In these situations, family members may need only limited help in revising their usual patterns to respond to changed circumstances. In other instances, maladaptive relationships and communications in the family are or become the primary or an additional source of stress. In these situations, family members’ means of interacting with one another compromise their ability to respond to and cope with the inevitable challenges they face as they move through the life course. Consider the following hypothetical situation: The McKenzie-Brown family (Charlene Brown, Mark McKenzie, and their three children) are hit head on in their car by a drunk driver. The youngest child, Maureen, age 3, is killed instantly. The other four members of the family are injured, but all fully recover. Whether the family is able to recover from this traumatic and unexpected event

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depends upon a number of factors, including members’ functioning prior to Maureen’s death. Compare the following scenarios: Scenario 1: Prior to the accident, the parents enjoyed a supportive and loving relationship with one another and with their children. They find time to be a couple, but they also are engaged with their children. Family members experience a sense of intimacy with one another, but their uniqueness as individuals also is respected. The family enjoys relationships with the external environment, including extended family, friends, neighbors, coworkers, and congregants from their church. While family members are grief-stricken, they have not only themselves to turn to, but also a wealth of others who provide them with instrumental and emotional support. If needed, the family is open to professional assistance to help members deal with their grief because they are accustomed to using such resources in their external environment. Scenario 2: The parents had a tense and conflicted relationship that preceded the death of their child. In the past, they considered splitting up but decided that they should stay together for the sake of their children and because they would have a difficult time financially if they lived apart. Brown and McKenzie work long hours and have little time to engage with their children. They have frequent fights about discipline and who should do what around the house. The family maintains little contact with extended family members; Brown’s parents disapprove of her living with a man to whom she is not married, and McKenzie has been estranged from his family for many years. The family has few supportive connections in the external environment, although the oldest child, Nathan, is in elementary school and does have a few friends and an interested and committed teacher. Maureen’s death leads to intense feelings of grief for the family, but the parents resume their normal routines and assume that the children will do the same. Soon, however, tension escalates between the parents, and Nathan begins to have trouble concentrating in school. Nathan’s teacher contacts the school social worker, and in turn, the social worker contacts the parents and only at that point learns about Maureen’s death.

These two scenarios represent opposite ends of a continuum that reflects family functioning. In the first, the family has been functioning well, providing its members with a sense of connection and belonging, as well as allowing individuation. The family members have a shared identity as a unit but also are able to access resources in the external environment. The members’ sense of connectedness to one another and their willingness to use outside resources enhance the likelihood that, painful though the process will be, they will slowly move beyond their grief and, as a result, become more resilient and stronger as a unit.

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In the second scenario, the family already is in trouble due to the parents’ conflict. Maureen’s death exacerbates these stressors and in turn creates new ones—in this case, Nathan’s behavioral problems. This family has few external sources of support and is unlikely to request help to deal with Maureen’s death. The family’s difficulties are likely to come to the attention of professionals only if Nathan’s teacher develops concerns about him and asks for help. Otherwise, their maladaptive ways of dealing with one another and with Maureen’s death are likely to become even more entrenched and challenging. All families exist somewhere on this continuum. Well-functioning families are better able to manage the challenges of a traumatic event and the environmental pressures that they will inevitably face. When families already are struggling, maladaptive dynamics are likely to be exacerbated—creating even more stress—when members face additional life stressors. Even when families are functioning reasonably well, external events can overwhelm members’ abilities to cope, particularly when key protective factors like external support are missing. We turn to the processes and dynamics that are central to family functioning and the members’ ability to cope with life stressors.

INTERNAL FAMILY FUNCTIONS, STRUCTURES, AND PROCESSES

Families are bound together not only by ties of kinship or by legal rights and responsibilities, but also by self-definition. Census data, as well as data from other demographic studies, reveal that the traditional nuclear family, consisting of two married heterosexual parents and two children, is no longer the norm in the United States (https://www.census.gov/topics/families/families-and-households.html; https:// www2.census.gov/cac/nac/meetings/2017-11/LGBTQ-families-factsheet .pdf; https://www.statista.com/topics/1484/families/; http://www.stepfamily.org /stepfamily-statistics.html). Consider the following: • The average family size is 3.1 persons, and the average number of children under the age of 18 per household is less than 2 and has continued to decline. • More than 50 percent of all families in the United States are blended or recoupled families. • The number of families headed by a single parent—especially a single woman— has continued to rise. • The number of families compromised of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals continues to rise.

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These families confront the same stressors faced by the traditional nuclear family, but they also may face other challenges unique to their particular structure. Family Functions

The functions that have been ascribed to families across diverse cultures and historical eras are (1) providing resources to promote the survival of members, including shelter, food, and protection (instrumental functions); (2) meeting members’ needs for nurturing, acceptance, security, and realization of potentials (expressive functions); and (3) connecting members to the social and physical worlds outside the boundaries of the family. Procreation and socialization of children traditionally have been viewed as a primary function of a family, but this function is no longer as relevant for many contemporary family structures. Other social institutions have gradually taken over (wholly or in part) former family functions such as education, socialization, and healthcare. Thus, families develop ways to connect their members to schools, workplaces, healthcare services, day care and respite services, voluntary associations, and, for the affiliated, religious institutions. Family Forms

While the nuclear family structure has been viewed as ideal by some, those members still face pressures that exceed their ability to adapt and change. Two working parents and geographic mobility have become a significant strain for many families. These families may suffer from social isolation, heavy indebtedness, and other pressures, such as job loss or the fear of it in a global economy. Children’s involvement in extracurricular activities, as well as demands associated with their education, contribute further to members’ stress. Finally, reliance on and preoccupation with social media and technology often result in detachment of members from one another. Families with children headed by a single parent face unique challenges. The demands associated with parenting and managing a household (the instrumental and expressive functions) often are met by a single adult, rather than shared with another. The result is role strain and overload for the parent, as well as for children who take on adult responsibilities like childcare and housekeeping. Families headed by women are at far greater risk of being poor than their maleheaded counterparts. As a result of gender-based stereotypes, single fathers often face role ambiguity. In addition to these practical challenges, single-parent

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families often encounter negative stereotypes about their ability to effectively manage their households. These include sentiments such as “Boys need a father” and “Fathers don’t know how to nurture their children.” Blended families (or stepfamilies) face the challenge of merging two sets of expectations based upon members’ previous family structures and creating a totally new normative structure. Attempting to integrate children into the new family system as well as defining the roles and responsibilities of stepparents and noncustodial parents creates special challenges. Children living in the new family not only have a new stepparent, but also may have stepgrandparents, stepsiblings, and other adult kin who may or may not accept the new parent and children as relatives. Other family forms face challenges that reflect their nonconformity with what social norms dictate as “normal.” Families without children have become more common yet are often viewed as incomplete, and the adults as selfish. Despite the increased acceptance of same-sex marriage, same-sex families—with or without children—often face discrimination and stigmatization. Despite a lack of evidence, many people continue to believe that growing up in a same-sex family is unhealthy for children. Evidence does suggest that these families, and particularly children in these families, are more likely to be subjected to ridicule, intrusive questions, and ostracization (Trub, Quinlan, Starks, & Rosenthal, 2017). Further, when there are children, challenges may occur when choosing surnames and explaining that the family consists of two “mommies” or “daddies. Extended families that live together in the same household are prevalent around the world, but less common in the United States. Members of an extended family may be valuable sources of support, but their helpfulness may be limited by members’ unavailability due to geographic distance. Increasingly, younger adult children are moving back in with their parents out of economic necessity, while older adult children are called upon to provide care to their aging parents. Both of these situations may create stress and tension among members. As noted, all families exist on a continuum ranging from very adaptive to very maladaptive, regardless of their form. In the following section, we identify the dimensions along which we can assess how well a family is functioning, and therefore how well its members are able to respond to changing circumstances. Family Structure

Salvador Minuchin was one of the first theorists to apply a systems perspective to families and examine their structure. He focused on both the internal

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functioning of various subunits, or systems, within the family and the family’s relationship with the external environment. Minuchin’s conceptualization of subsystems reflects his view that a family’s ability to perform its functions and meet the needs of members depends upon how members organize themselves and relate to one another. He identifies three units of analysis: the family as a whole and how it relates to the external environment, each individual member of the family and how each relates to every other member in the family system, and how different subsystems in the family—defined by their function—relate to other systems in the family and meet their responsibilities (Minuchin, 1974). Boundaries

A basic concept associated with the structural perspective is the notion of boundaries, which characterize members’ relationships with one another. In order for a family to meet its basic obligations to members, the boundaries that define the family as a whole and the members and subsystems within it must be permeable. Permeable boundaries define the relationships between members within the family and the family’s interactions with the external environment. The family as a whole has a shared identity but maintains reciprocal relationships with the external environment. Within the family, permeable boundaries mean that individual members experience a sense of connectedness to one another, but they also are able to develop their unique and individual identities, and the subsystems (discussed in the next subsection) are independent of but also accessible to other systems and members in the family. Families are at risk of being unable to respond to changed circumstances and perform their basic functions when boundaries are either rigid or diffuse. When the family as a whole is detached from the wider social environment (a rigid boundary), members are unable to access the resources and support that the environment provides. In times of stress, this increases the internal tension among members, since they have only one another to rely upon. When individual family members are inaccessible to one another, this leads to a sense of alienation and isolation that undermines intimacy and a sense of belonging. In some families, the opposite situation exists. When the interactions of a family as a whole with the wider social environment are characterized by a diffuse boundary, this implies a lack of a shared identity and cohesiveness among members. While individual members may interact with the environment, their collective identity as a family is more or less nonexistent. Diffuse boundaries within the family imply that members lack a sense of autonomy.

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These three types of boundaries are points on a continuum, with rigid on one end, diffuse on the other, and permeable as the midpoint. All families can be placed at some point on the continuum; the farther from the midpoint on either end, the more maladaptive a family’s functioning is likely to be. In either extreme, members’ ability to adapt to changing circumstances and respond to stressful life transit