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

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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

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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

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Moment-to-moment assessment

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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 transitions and environmental pressures is compromised, as is the family’s ability to carry out its core functions. Subsystems

Minuchin identified four subsystems within a family that carry out its functions: spousal, parental, sibling, and parent-child. The functioning of each subsystem affects and is affected by every other one. Given the wide variety of family forms that exist, we use the term partner system to refer to the responsibilities associated with the spousal system, and executive system to refer to tasks associated with the parental system. The functioning of these two systems is relevant for any family. When there are children, the parent-child system and sibling system will be pertinent. Minuchin’s original conceptualization, with our refinement, is applicable to any family form and is not bound by any single set of cultural norms. Partner system. This system meets the needs for affiliation and intimacy (the expressive function) of the adult members of a family. The subsystem’s ability to carry out this function depends upon the ability of its members to accommodate the needs and abilities of other members in the system. Members are connected to, but also separate from, one another. Intimacy is encouraged, as is independence. This requires a permeable boundary around the members of the system. Healthy family functioning depends upon the members of this system being separate from, but also accessible to, others in the family; a permeable boundary exists around the partner system as a unit and other members of the family outside the system. The structural perspective does not prescribe how the members of this system will relate to one another to accomplish the subsystem’s function, only that their interactions must be complementary and reciprocal. What works for one member of the system must work for another. Cultural norms and standards are likely to influence the functioning of this system, as are the members’ unique experiences and backgrounds. Consider the following scenarios, which we will expand upon as we continue this discussion: • Hideo and his wife, Aiko, head the Japanese-American Takahashi family. They are proud of and embrace their Japanese heritage. Consistent with this heritage, Hideo plays the more dominant role in the partner system when it comes to issues

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such as when and how he and Aiko will be sexually intimate, how they will express emotional intimacy with one another, and how they will conduct themselves as husband and wife. Hideo is not domineering; he does attend to the needs and wishes of Aiko. However, he does have more influence over how they relate to one another—something that Aiko expects and supports. • Gwen Freeman and Martha Walters head the Freeman-Walters family. Their partner system also is one in which one individual—Gwen—plays the more dominant role in terms of setting the expectations for their relationship. Unlike Aiko, however, Martha is dissatisfied with this arrangement, and she says that at times she feels “suffocated” by Gwen’s controlling behavior.

The power dynamics are similar in these two partner systems, and yet it is only the Takahashi subsystem that functions well and meets the needs of its members. We now ask readers to consider two additional scenarios: • Mariah, who is the mother of three children by two different fathers, heads the Sloane family. The father of one of her children died, and the other father is incarcerated. Mariah has a close relationship with her mother, her sisters, and her brothers, who provide her with support and intimate connections. Mariah also enjoys close relationships with several friends. • Nichole, also the mother of three children, heads the Monroe family. Like Mariah, she has no contact with the fathers of her children. She has been estranged from her family for some time and has few close friends. She is lonely and often seeks out emotional support and comfort from her oldest child, Demetri, age 10.

A single adult heads both families. While a clearly defined partner system is absent in both, this is maladaptive only in the Monroe family. Mariah has her emotional needs met through family and friends. Nichole, on the other hand, relies upon her children to meet her needs for intimacy and connection to others. Executive system. This system often contains the same family members as the partner system, but its function is quite different. While the partner system attends to the affective needs of adult members, the executive system is task-oriented and focused on household and family management (instrumental functions). Tasks include, among others, assignment of chores, managing a budget, and, when there are children, child-rearing and discipline. If this system is to fulfill its task-oriented functions, it must be characterized by reciprocity and complementarity, as in the partner system. Cultural norms and the individual characteristics of the members will influence how they will enact their respective roles within this system. Although the executive and

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partner systems have different functions, they will work in complementary ways. Consider the following: • Hideo is the primary decision-maker in the Takahashi family. While Aiko assumes primary responsibility for parenting their two children, Hideo makes most of the decisions concerning the family’s finances and discipline of the children. The Takahashis present a united front to their children, and while the children have some input into some decisions, it is understood by all that Mom and Dad are in charge. • In the Freeman-Walters family, Gwen Freeman has assumed the dominant role in the executive system, making most of the important decisions, which parallels her role in the partner system. Martha Walters resents this and would prefer to have more of a voice in how they discipline their two children and who is tasked with performing other necessary responsibilities in their household. This resentment has led to a lack of unity in parenting. Gwen recently sent their oldest child to her room without supper when she talked back at the dinner table. Without Gwen’s knowledge, Martha took dinner to her daughter, telling her that Gwen was “mean.”

In the Freeman-Walters family, the conflict that exists in the partner system has spilled over into the executive system, undermining Gwen and Martha’s ability to parent effectively. The opposite possibility also exists. Conflicts may surface in the executive system that then manifest themselves in the partner system. In either case, the problems become self-reinforcing. For example, Clinton Morris and Chris Huffman have been partners for five years. Both are professionals who work long hours. Chris in particular is required to do a good bit of traveling, which results in Clinton having to do most of, as he says, “the grunt work” around their house—grocery shopping, taking care of their dogs, cleaning the house, dealing with household repairs, paying the bills, and the like—something he deeply resents. This resentment is apparent in Clinton’s increasing reluctance to be affectionate with Chris, go out on dates, and engage in a sexual relationship. The partner and executive subsystems may include additional individuals. For example a relative such as a grandparent may be part of the executive subsystem, and in stepfamilies, biological and stepparents often share parenting responsibilities and decision-making regarding child-rearing. Members of communal families comprised of several adults—with or without children—often share responsibilities in both of these systems. While there is always the risk of “too many cooks in the kitchen,” when expectations are clear and agreed upon, multimember executive and partner systems can function as well as those with only one or two members.

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Sibling system. In families with children, this system, which includes only siblings, provides members with an opportunity to engage with others with similar levels of power. In this system, members have the opportunity to learn how to relate to their peers and develop skills of cooperation, negotiation, and compromise. In interactions with parents, children are often told what to do, even when they have a voice. In the sibling subsystem, though, members are on a more equal footing, even when there are significant age differences. Consider the following scenarios: • In the Sloane family, Mariah is the sole member of the executive system. She is responsible for making the decisions in the family, although she is responsive to input from her three children when it comes to considerations such as chores and family outings. She also takes into account her children’s opinions when determining punishment, consistent with their ages. For instance, her 6-year-old son, Laquan, has far less say in how he is disciplined or any other decisions about his actions than her daughter, Naomi, who is 14. The sibling system in the Sloane family includes Naomi, Brittania, age 10, and Laquan. Because Mariah works long hours, she relies on Naomi to make sure that her younger siblings do their homework when they come home from school, and she often asks her to start dinner. While Naomi has had to assume some executive responsibilities, she still is able to engage with her brother and sister as their sister, not as their parent. The siblings laugh, play, and sometimes fight. While Mom sometimes has to intervene, the three children are learning how to interact as peers without her guidance. • In the Monroe family, single parent Nichole has turned to her oldest child, Demetri, for support and affection. This has led to problems in the executive system; Nichole tends to go easy on Demetri when it comes to discipline, and she is much harsher with her other two children, Mason, 8, and Danita, 5. Demetri’s siblings resent their brother’s status as “Mom’s favorite,” and this has led them to avoid playing with him and to gang up and pick on him.

Out of necessity, Naomi assumes some responsibilities that are associated with the executive role. However, her mother remains in charge, and this is understood by Naomi and her siblings. Despite assuming these responsibilities, Naomi is still able to be a 14-year-old, and this includes playing with her siblings. In contrast, Nichole’s reliance on her oldest son for emotional support has led her to be lax in disciplining him, which in turn has resulted in him being excluded from a relationship with his siblings. In a family with only one child, the sibling system is nonexistent. However, others, including the only child’s friends and relatives like cousins, can meet the function of that system.

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Parent-child system. This system includes different generations within a family and allows members to interact with one another in a more informal and social way. Parents remain parents, but parents and children play and indulge in recreational activities with one another. This is the system in which parents and children have fun together, and it is reflected in game or movie nights and vacations. Consider the following examples: • Keiko Takahashi, age 12, is a gifted dancer and has been taking tap and ballet lessons for a number of years. Her parents never miss her concerts, and they have established a tradition of going out for a celebratory dinner afterward. This provides all family members with a chance to socialize and have fun. Her mother, Aiko, is much more involved with Keiko’s dancing; she typically stays for practices, shops with her daughter for dance outfits, and takes her to performances by other artists. These experiences provide both mother and daughter with much enjoyment and allow them to interact with one another in a way that is very different than when, for example, Mom tells Keiko to clean up her room. Keiko’s dad is not excluded from this (the boundary around Mom and Keiko’s relationship is permeable), but this provides mother and daughter with special bonding time together. Keiko and her father also have down time together, and her brother, Izumi, enjoys similar relationships with each of his parents. In the Takahashi family, as in many others, the parent-child system often revolves around shared interests and hobbies. • In the Sloane family, Mariah’s responsibilities as a working single parent mean that she often has limited time and money to engage in activities with each of her children. However, she does make time for family movie night once a week. Several times a month, she treats her children to pizza night out, which provides all members with an escape from their normal routine and a chance to socialize and catch up on one another’s lives. For these family outings, she prohibits the older two children, Naomi and Brittania, from bringing their cell phones to the table. • The tension and conflict in the partner and executive systems in the FreemanWalters family are reflected in the parent-child system. Martha Walters and her two children spend a good bit of time together, going to movies, taking hikes, and the like. She attends her children’s school and sports events. Gwen Freeman wants and tries to find time to relax with her children, but she rarely does, usually because the children are not interested in spending time with her. Complementarity of Subsystem Functioning

These scenarios illustrate how central subsystems are to the adaptability of the family and its ability to fulfill its functions and meet the needs of its members. They also reflect the following considerations:

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1. Boundaries exist both around the subsystems and within them (when there is more than one person in the system). Boundaries within the system complement those that surround it. 2. The functioning of one system affects the functioning of all others. 3. There is no universal, one, right way for family members to enact their responsibilities within the various subsystems. What is important is whether the members are all on the same page, have a clear understanding of what is expected of them and others, and have the ability to meet those expectations. 4. The functioning of each subsystem reinforces all the others. 5. The more rigid or diffuse the boundaries that surround a system and the members within it, the more likely it is that family members will be unable to adapt to changing circumstances. 0 Coalitions and alliances that exclude some members undermine all members’ sense of connectedness to one another, as well the family’s resilience. 0 When members are too connected or attached to one another (the boundaries are diffuse), independence and autonomy are discouraged.

Readers will note that we did not include blended families or stepfamilies in the previous examples in this chapter. The functioning of subsystems in these families often is quite complex and presents numerous challenges to members. Blended families are at much higher risk of separation and divorce, and it has been assumed that this is the result of the partners’ problems with intimacy that were apparent in their first (or subsequent) relationships (Ganong & Coleman, 2018; Saint-Jacques et al., 2016). But it is equally—if not more—likely that the challenges faced by the members of these families as they merge into a new family unit is responsible (Cartwright & Gibson, 2013; Martin-Uzzi & Duval-Tsioles, 2013). For example, in a blended family with children, the executive system may include the biological parents and the stepparents. Challenges that members of this system face include defining the role played by the stepparent in decisions regarding the nonbiological child or by the noncustodial biological parent. The functioning of the sibling and parent-child systems can be compromised when they include members from two different families, each of which had a different normative structure (i.e., a different way of interacting with one another). We now turn to these norms—the processes—that guide how members relate to one another. Family Processes

Families develop their own structure for dealing with role and task allocation and issues of authority and decision-making. This structure shapes the relationship

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and communication patterns and in turn is influenced by the nature and quality of those patterns. Family processes guide how members interact with one another. We now turn to these essential aspects of family functioning, each of which is dependent upon and reflective of the others. Communication

Family members’ communication patterns reflect and promote adaptive and/or maladaptive family functioning. Communication—whether verbal or nonverbal— is an imprecise way of conveying to others our thoughts, feelings, opinions, and experiences. Therefore, to be accurately understood by other family members, individuals must strive for congruence in their verbal and nonverbal communication: that is, what is said verbally should be consistent with what is said nonverbally. When communication is not clear, members must be able to ask for and then receive clarification about what they have heard. Adaptive communication in families requires a constant give-and-take, with members clarifying and qualifying what they are saying to one another. Members strive to say what they mean and mean what they say. When this is not the case—when messages are inconsistent and incongruent, and members are unable to ask for clarification—this leads to confusion and undermines the family’s capacity to meets its functional responsibilities. The recipients of incongruent communication (particularly if they are children) often are left feeling responsible and at fault for not understanding what is being asked of or communicated to them. Virginia Satir (1983, 1990), a renowned family theorist and therapist, identified the consequences for the family and its members when communication is incongruent and not open to clarification and qualification. Double-bind communications put recipients in a no-win situation because they include two inconsistent messages. If recipients comply with one message, they cannot comply with the other. The more often this type of communication occurs and is not or cannot be questioned by the recipient, or is not clarified by the sender, the more problematic it is for all those involved. For instance, consider the following situation: In the Monroe family, the parent, Nichole, often turns to her son Demetri for comfort and emotional support. Demetri is invited to spend the weekend camping with the family of a friend and asks his mother if he can go. In response, Nichole loudly sighs, looks sad, and says, “Well, if you really want to go, I guess you can. But I’ll be all alone with your brother and sister. I’ll miss you.” In this one

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communication, Demetri hears, “Go, but don’t go.” He is only 10 years old and is unlikely to ask his mother for clarification. It is doubtful that he even understands the catch-22 position he has been placed in: does he go have fun with his friend and “abandon” his mother, or stay home with his mother and be disappointed (and feel resentful)?

Double-bind communications are often the result of triangulation. A family member—often, but not always a child—is caught in the middle between other members’ conflict: In the Freeman-Walters family, there is tension in the partner and executive subsystems between Gwen and Martha. Their oldest daughter, Sarabeth, asked Gwen if she could spend the night at a friend’s house, and Gwen said no because Sarabeth had not done her weekly chores. Martha overhears this conversation and then says Sarabeth can go. Caught in this double-bind situation, Sarabeth will anger or disappoint one of her mothers. She cannot win.

Satir also notes that when we communicate with one another, we are always sending a message about the messages we send and about the people to whom we send them. This metacommunication—what a family member is really saying—can be conveyed verbally or nonverbally, but it is rarely conveyed intentionally. The more unclear and ambiguous the metacommunication, and the more unwilling the sender is to clarify the message, the more confusing it is to the recipient. For example, when Nichole responds to Demetri’s request to go camping with a friend, she is saying something like,” Love me; take care of me.” Caught between her parents, Sarabeth is hearing, “Pick me, not her.” The following exchange occurs between Clinton Morris and Chris Huffman over dinner: clinton: I spent most of the day washing the windows. They sure needed it! chris: Uh. clinton: I think tomorrow I’ll mop the floors. It’s been a while. chris: Sounds like a plan. clinton: I can’t fucking believe you!Clinton gets up and storms out of the room. chris: (yelling into the next room) What the hell is wrong with you? We’re sitting here having a nice dinner and you get some bug up your ass. What the fuck?

In many cases, a family member sending a message assumes that the recipient understands what is being said without actually saying it. In other words,

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the family member assumes that others are mind readers. Readers will recall that Clinton resents the amount of time that Chris spends at work, leaving him to take care of their home, in addition to managing his own career. When he informs Chris about what he has been doing, what he is really saying is “Thank me for doing all this ‘grunt work’ ” and/or “Look at all I do for us.” Chris does not understand that this is what is being said and does not provide the response that Clinton needs and wants, which leads to yet another argument between them. Adaptive communication in families means that secrets are kept to a minimum (Wise, 2005). This does not mean that all members share all information all the time. For example, a couple’s conversations to resolve a problem with sexual dysfunction or parents’ discussion about a punishment for a young child would not (and should not) include other family members. However, when families engage in keeping secrets—or denying the existence of a taboo subject—this inevitably creates problems for some or all members, since they are likely to be aware of the secret even if it is not acknowledged or is actively denied. When family secrets exist, overall communication patterns are likely to be ambiguous and contradictory. In the following example, a family’s secret is being kept from outsiders and is not acknowledged among the members themselves. Keeping this secret has adverse effect on the emotional and social development of the children. Tom is the youngest of six children and the only one still at home. His teachers are concerned because he is failing most subjects, has no peer relationships, and appears to be continually angry with everyone. When he meets with the school social worker, Tom reluctantly reveals to her that his mother has a drinking problem, which has led to teary and angry outbursts directed at his dad and him. His attempts to talk to her, his siblings, or his father about this have been met with silence or justifications such as “Mom just likes her wine” or “Your mother doesn’t have a problem—you’re just too sensitive.” He expresses to the worker his anger at his mother for drinking and for treating him like a baby when she is drunk. He also is angry with other family members for “pretending” there isn’t any problem when he thinks there is. However, he also is angry with himself and feels confused, saying, “No one else in my family feels like I do [about his mother], so maybe it’s me who is crazy.” This self-doubt, coupled with his anger and embarrassment about his home life, leads Tom to isolate himself from peers and lash out at others in anger.

The social worker determines that Tom’s mother’s drinking problem is not a new family issue, but Tom’s entrance into early adolescence, coupled with his now being the only child still at home, has made him more aware of his mother’s

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behavior. Because the rest of the family deals with this problem by denying its existence, the worker understands that all of Tom’s energy is invested in maintaining the secret and questioning his view of his family, with little left for doing schoolwork or building new relationships. Affective Expression

Family members need to know that they are valued. The ways in which members convey this to one another are essential to the family fulfilling its expressive function. Family members also must develop ways of expressing displeasure with or anger at one another, because, as we discuss next, conflict is inevitable. There is no one healthy or right way for members to express themselves affectively. Some families—or certain members of families—may be “touchy-feely” with their feelings, while other families or family members may be more restrained. Some may always say, “I love you” verbally, while others may convey this nonverbally, through gestures. What is important is that members have a shared understanding of how to convey feelings and what affective communication and gestures mean. This depends upon the aspects of adaptive communication identified earlier in this chapter. Hideo and Aiko are restrained in their displays of affection for one another, which is consistent with their cultural identity. In public or in front of their children, they rarely hold hands, kiss, or display affection for one another. They also are reserved in their displays of affection (or anger) with their children. However, all four members of this family experience a deep sense of connection to one another and understand that whatever emotion is being conveyed is genuine. In contrast, Gwen and Martha routinely say, “I love you” to one another, but this is not supported by their actions. They express affection, but the expressions are meaningless (and at some level, every member of the family knows this). Anger is generally not overtly expressed; rather, it is manifested in their relationships with their children. Conflict and Disagreement

Conflict and disagreement are inevitable aspects of family functioning. In adaptive relationships, conflict and disagreement are directly addressed, which reflects members’ tolerance for difference and encouragement of independence in thought and action. Members’ arguments rely upon the give-and-take process of clarification and qualification, as well as statement and restatement of

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positions and opinions. Ideally, this process leads to a resolution, which may involve negotiation and compromise, parties agreeing to disagree, or one person conceding to another. The specific form that arguments take will depend upon a variety of factors, including cultural, but the process is important. Family members openly work through and resolve the inevitable conflicts that surface in their relationships with one another. This process conveys respect and affirms members’ uniqueness. When conflict and disagreement are not acknowledged, this may result in what is referred to as pseudomutuality. Members seem to get along, and conflict appears to be absent, but this masks an underlying tension, which tends to intensify and worsen the longer it goes on. At the other extreme, family members may disagree—often loudly and violently—but there is no resolution. Members talk (or scream) at one another, not to one another. At either extreme, a family’s inability to address and resolve conflicts undermines its coping capacity and resilience and its ability to achieve its basic functions. When conflicts and disagreements are not directly addressed and resolved, this also leads to triangulation, as reflected in Sarabeth’s position of being caught between her two mothers. Triangulation also occurs when attention is diverted from the underlying conflict onto another person or issue. Rather than focus on and resolve an underlying conflict, members devote their attention toward another family member, as in Sarabeth’s case, or an issue. For example, in both the partner and executive systems, there is conflict in the Clinton Morris–Chris Huffman family. One way to avoid the hard work associated with resolving their disagreement is to focus on an issue—perhaps Chris’s work schedule—rather than the underlying tensions that exist in their partner relationship. While not necessarily intentional, both of them assume that if Chris did not have to travel so much, everything would be okay in their relationship. The couple’s disagreement over Chris’s work exacerbates the tensions in their partnership, and the tensions in the partner system intensify the disagreements over his work. Therefore, it is likely that even if Chris’s work schedule were resolved, another issue would surface that would lead to disagreement. The underlying tension would not disappear. Separateness and Connectedness

Family relationships are a balance of intimacy and autonomy. Connectedness among members promotes a sense of belonging, which affirms the members’ identity and worth. Separateness promotes feelings of competence and selfefficacy. This balance is always in flux because members’ needs in these areas

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change. The relationship between a parent and a toddler will be characterized by more connectedness than separateness. As toddlers age, they will demand and need more independence, while still requiring a sense of connectedness to their parents. Adjusting to these changes is facilitated by permeable boundaries around subsystems, open lines of communication, and the ability to negotiate and resolve differences. When there is too much distance—or too much separateness—between members, this leads to disengagement and feelings of isolation and alienation. Too little distance—too much connectedness—between members leads to enmeshment, which undermines the members’ sense of confidence in themselves and thwarts growth. The Takahashi and Sloane families have learned to balance their members’ needs for both connection and separation. In many of the other examples given in this chapter, the families have been unable to strike the right balance. Gwen and Martha are disengaged from one another in the partner and executive systems, while their two children are enmeshed with Martha. And in the Monroe family, Demetri is enmeshed with his mother but disengaged from his siblings. Relationships with Extended Family and Significant Others

Families rarely exist in isolation, and when they do, they are at risk of being overwhelmed during times of stress. Adult members’ relationships with parents, siblings, close friends, and, when relevant, ex-partners and their extended families and, in families with children, their relationships with biological and stepparents and extended family must be negotiated. For example, families need to decide what role, if any, will parents of adults in the partner and executive systems play in their functioning. What role does a noncustodial parent play in the executive system that includes the custodial parent and partner? While this process of negotiation is rarely undertaken intentionally, at some point members will establish expectations and rules that govern these relationships. Once again, permeable boundaries and clear and open lines of communication will facilitate this negotiation. Family Culture

A family’s structure and processes combine to produce a normative culture that is unique to that particular family. Over time, a family creates a set of norms that establish acceptable and unacceptable behaviors: “oughts” and “shoulds” and “ought nots” and “should nots.” These expectations rarely have been explicitly discussed and agreed upon, but they come to define—often in quite rigid

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terms—what is allowed and what is not. Further, it can be difficult to identify (for family members and the worker) what the norms are until the members violate them. Traditions and Rituals

Families develop traditions and rituals that reflect their experiences through time. These traditions reflect and reinforce the normative processes previously identified. Especially important in family life are rites of passage that surround individual and family transitions. These include observances of biological transitions, such as birth, male sexual maturation (in some cultures), and death, and of social transitions, such as graduation, first job or new job, promotion, engagement, marriage, anniversaries, birthdays, adoption, return from war, and retirement. Some rituals help families cope with change or discontinuity, while others support stability in family life and bind the members to one another in shared, memorable experiences. Rituals help maintain channels of communication or may open closed channels, and they maintain and deepen relationships or restore fractured ones. Traditions provide family members with a sense of belonging and reinforce a shared identity. Family rituals in adaptive families are responsive to their members’ needs as the families themselves evolve. A family’s rituals around holidays will of necessity change as new members are added (e.g., a child marries or has children) and lost (e.g., a parent dies or a member moves far away). Traditions become maladaptive and undermine a family’s functioning if they reinforce destructive myths, promote illusions, deny secrets, or reinforce maladaptive norms, like enmeshed or disengaged relationships. For example, in Tom’s family, holidays were a time when his mother would drink even more than usual. Rather than speaking about her behavior directly, family members would ignore it, explain it away, or, in the case of his older siblings, leave events early. Family Development, Worldview, and Transformation

Like individuals, families evolve and change over time in response to the maturing, loss, and addition of members. A family’s evolution reflects additional forces, including cultural, social, political, and economic ones. Traditional timetables of many life transitions are disappearing. With increased longevity, many of today’s elders do not regard themselves as old until their late seventies or early eighties. We also see 65-year-old caretakers of their 85-year-old parents, as well as teenage mothers rearing their infants and adults postponing childbearing to

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the latest biologically possible age. Therefore, fixed, age-connected times for learning, selecting intimate partners, marrying or remarrying, first-time parenting, changing one’s career direction, retiring, and many other life changes have become relatively independent of age. Members develop in tandem, but not necessarily at the same pace or in complementary ways. Individuals within a partner system grow and develop over time. Ideally, the ways in which they develop deepen their commitment to the relationship. This is most likely to occur when permeable boundaries have been in place that allow individuation and differentiation. However, as they mature, partners’ paths may diverge, increasing the risk of disharmony. Parents and children also are continuously in the process of maturing. The constant attention and effort that young children require give way to less attention and greater autonomy as they become teenagers and finally adults. Over time, families also construct a unique worldview, defined as the members’ shared, implicit beliefs about themselves and their social world. The worldview shapes the family’s basic patterns in living and experiences in the environment. It shapes the family’s development, which in turn deepens the worldview. A painful life event or other life stressors that cause serious discontinuity in family life may require the family to change its ways of functioning, which may lead to a shifting worldview. A family’s growth and development occur in response to first- and second-order life issues. First-order life issues represent life transitions that occur frequently and are usually expected, fitting into the continuous flow of family life. They include developmental transitions of individual members, such as puberty, pregnancy, and aging processes, and social transitions such as school entry, work, marriage, retirement, and the like. Life transitions from birth to old age present both individual members and the family as a whole with new requirements and new opportunities for mastery and growth. Most families may experience first-order life issues as challenges rather than stressors and manage them relatively smoothly, without serious disruption. The family’s worldview does not need to be changed. Several new behavioral sequences are sufficient as the family learns to manage the issue effectively. As the new behavioral sequences appear, outmoded sequences drop away, but this adaptation depends upon the adaptive family processes discussed previously. Second-order stressors consist of serious, often unpredictable life events ranging from natural catastrophes to family violence, addiction, unplanned and unwanted pregnancy, sudden and serious mental disorder, onset of disability or chronic illness, job loss, separation and divorce, and premature loss of a loved one. These events represent severe discontinuities in the routine flow of family

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life and put the family in harm’s way. Second-order stressors also include poverty, disenfranchisement, and oppression, which themselves generate multiple second-order life issues. First-order life issues become problematic when a family’s normal way of engaging with one another undermine the members’ ability or willingness to adapt. In this case, a first-order life issue may be perceived as threatening, either because of the meaning that the issue has for the members or because of the absence of internal or external resources needed for moving through it. For example, a child leaving home to live independently is an expected aspect of individual and family growth. In families where there is conflict in the partner and/or executive systems, this transition may be experienced as a threat and may upset the family’s balance. Readers will remember Nichole Monroe’s situation. Having little in the way of support from family or friends, she has relied heavily upon her children, particularly her older son, Demetri, to meet her needs for intimacy, support, and connection. As the oldest child, and the one on whom his mother most depends, Demetri is likely to struggle to assert his independence as a teenager and may be conflicted about his desire for more independence and his concern for his mother’s well-being. Second-order life issues require the family to go beyond the process of simply adding new behaviors and dropping outmoded ones. Because of the severe discontinuity and the greatly changed conditions imposed by second-order life issues, many families require formal or informal help to change the fundamental characteristics embodied in the family worldview. These changes include the reorganization of its structure of roles, tasks, and routines, and redefinition of the family’s values, norms, and meanings. In some instances, a family may have to modify its goals, plans for the future, and interpretation of its past. While these and other modifications are going on, family members also must regulate the accompanying anxiety, guilt, depression, resentment, shame, anger, or despair that they feel so that these feelings do not interfere with efforts to change. For example: Mrs. Abrams, a 52-year-old, white, Jewish woman, is the mother of three daughters, ages 27, 25, and 23. She has sought help from the social worker at the psychiatric hospital from which her youngest daughter, Rebecca, is to be discharged. Rebecca was admitted to the facility after an attempted suicide, and she has been diagnosed with major depression with psychotic features. She will be moving back home with her parents. Mr. Abrams is being treated for a heart condition and is also in chemotherapy for colon cancer. Mrs. Abrams is his primary caretaker.

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The oldest daughter has two small children, works full time, and relies upon her mother to help with the care of her children. The second daughter also works and looks to her mother for advice. Both daughters are very upset about their father and look to Mrs. Abrams for comfort and emotional support. Although the two oldest daughters express concern about their sister, Mrs. Abrams worries that they will resent the amount of time she will need to devote to Rebecca when she is discharged. The family has limited involvement with its social environment. The couple has few friends, there are no relatives other than the daughters, and finances are limited. Mrs. Abrams says that she has come to terms with her husband’s poor health, but Rebecca’s disorder “came out of the blue and is a shock to my system. I don’t know how to cope with it and I don’t understand it.” She worries that somehow she is at fault for Rebecca’s condition. She also feels guilty that she cannot be as available to her other two daughters as they would like her to be. She also reluctantly acknowledges feeling angry and cheated as a woman engaged in caregiving of multiple others, who has not really lived for herself.

Mrs. Abrams’s view of the problem is her inability to meet the needs of her daughters and husband and manage the stress associated with her husband’s medical issues and her youngest daughter’s mental health. Even though her children are grown, they continue to depend heavily upon their mother’s support, suggesting a certain amount of enmeshment. This already has started to interfere with the oldest daughter’s marriage, since her husband complains about her need to talk to her mother every day, saying, “You can’t even go to the bathroom without getting your mother’s permission!” The social worker realizes that Mrs. Abrams’s difficulties reflect the Abrams family’s inability to manage the second-order issues associated with Mr. Abrams’s health and Rebecca’s mental health. Throughout its life course, the Abrams family has eschewed the support of others, preferring instead to turn to one another in times of stress. This has burdened its members, particularly Mrs. Abrams. If the difficult life issues currently facing the family are to be managed successfully and the new reality of Rebecca’s mental health issues incorporated into the family worldview, a transformation of its structure of roles, tasks, coping modes, goals and expectations, and views of the environment will be required. The social worker understands that Rebecca’s suicide attempt revealed underlying problems in the family, which created yet more stress on its members. The worker’s assistance at this point in the family’s evolution must focus on assisting them in addressing the present stressors they face. Her intent will be to help them modify their ways of interacting with one another so that they are better able to meet first- and second-order issues they will face in the future. Table 10.1 summarizes key family terms and concepts.

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Table 10.1 Key Family Terms and Concepts Boundaries

Permeable, diffuse, and rigid

Subsystems

• Partner: Meets the needs for affiliation and intimacy of adults in the family • Executive: Performs instrumental/task-oriented functions within the family • Sibling: In families with children, allows members to learn about cooperation and competition • Parent-child: In families with children, meets members’ needs for recreation and social time

Communication patterns • Double-bind communication • Metacommunication • Affective expression • Conflict and disagreement negotiated Triangulation

Members focus on another member or an issue rather than address conflict/disagreement

Pseudomutuality

The outward appearance of cohesiveness masks underlying tension/conflict

Separateness and connectedness

Families establish balance of autonomy of and intimacy among members

SOCIAL WORK FUNCTION, MODALITY, METHODS, AND SKILLS The Social Worker and Maladaptive Family Structure and Processes

Families facing life transitions, traumatic life events, and environmental pressures may have difficulty coping with such stressors due to maladaptive relationship and communication patterns. In other instances, family members’ interpersonal processes are themselves a source of stress. Finally, a significant life stressor— such as the death of a family member—may lead to maladaptive patterns. In all instances, the social worker’s function is to help members identify the interpersonal processes that are creating stress, communicate more openly and directly, and develop greater reciprocity and caring in their relationships with one another. This may require that the worker help members discard some behaviors and adopt new ones, or help the family develop a new worldview that restructures family roles, tasks, and goals and incorporates the new reality posed by the critical life issues in question. With the social worker’s help, the family transforms itself into a more functional unit that can cope with current stressors and better support the needs and growth of all members in the present and the future. Families rarely seek assistance with their internal functioning and processes. A request, offer, or mandate for assistance usually stems from an identifiable

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stressor. In previous examples in this chapter, we have seen how a family’s stressors came to the attention of a social worker as a result of a specific issue: the health problems of the daughter and father in the Abrams family and Tom’s behavioral and emotional problems in the classroom. In most instances, the family sees the problem as limited to a specific stressor rather than underlying dynamics that it creates, reflects, and/or exacerbates. For this reason, contemporary approaches to family intervention are stressor (problem) focused. The approach to family work that best exemplifies this orientation is known as strategic, first described by Jay Haley (Haley, 1976; Haley & Richeport-Haley, 2003). Emphasis is placed on helping family members modify patterns of interaction that compromise their ability to cope with the present stressors and to carry out basic family functions. The desired outcome also is to enhance members’ collective resilience and improve the family’s overall ability to meet its functional responsibilities (Van Hook, 2014). The strategic model of family intervention has been widely studied, and its effectiveness is supported for a range of family types and family challenges in varied practice contexts (Horigian, Anderson, & Szapocznik, 2016; Szapocznik, Muir, Duff, Schwartz & Hendricks Brown, 2015). The methods and skills identified next readily fit within this strategic model. Professional Methods and Skills

When working with a family, the social worker forms an alliance with its members. Social workers mediate current internal structures and processes that undermine the members’ ability to manage present-day stressors and the family’s ability to perform its essential functions. Joining Methods and Skills

Joining skills allow the worker to discover and foster an understanding of the family’s unique culture and worldview (Goldfarb et al., 2010). Affirming. The worker seeks out and affirms positives. Affirmation builds on the strengths of individual family members and the family as a whole. In addition, the worker helps members modify negative perceptions that they may have of one another. The worker does not overlook the challenges that the family faces but starts from and conveys the position that every family has strengths. Tracking and monitoring. When they meet with the worker, members’ interactions are likely to reflect the maladaptive patterns that require intervention.

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Therefore, social workers must note these interactions, be sure that their interactions with members do not reinforce them, and begin to interrupt and alter them. This skill also requires social workers to attend to members’ nonverbal reactions and be prepared to point out and address them directly. Creating a therapeutic context. Social workers must establish a climate in the sessions that promotes honest and respectful discussion between and among members. This allows the members to feel competent and believe that their voices will be heard and that change is possible. Because members’ interactions with one another are likely to become entrenched, the worker also needs to establish and maintain expectations for how the members interact with one another that are consistent with adaptive family functioning. Exploring and respecting the family’s worldview, rituals, myths, and traditions. Social workers appreciate and respect a family’s unique worldview and how this is reflected in associated roles, tasks, processes, and structures. Based upon this understanding, the worker then assists the members in adopting a worldview that is more adaptive and functional and helps them make the necessary adjustments to their internal processes and structures. The worker also may need to point out family traditions and rituals that reinforce any maladaptive structures and processes and helps the members make changes. In the following example of a first session, the worker’s uses these skills with members of the Rodriguez-Guzman-Salazar family. In chapters 6 and 9, we introduced readers to Maria Rodriguez, a middle school student who has been truant and had to repeat the sixth grade. Dennis, the school social worker, meets with Maria during school hours, but he also has a meeting with her family— her mother, Carmen Rodriguez, her 11-year-old brother, Javier Rodriguez, her cousin, Lupita Guzman, and Lupita’s boyfriend, Roberto Salazar. Dennis is aware that: Lupita and Roberto are undocumented but their two children were born in the United States; Maria’s mother is diabetic and struggles with an addiction to alcohol; and the family is living in substandard, cramped housing. Dennis believed that this meeting would help him better understand Maria’s school difficulties in a family context. We noted in chapter 6 that, as a young white social worker, Dennis anticipated that the family members might have some reservations about him and his ability to be helpful. Dennis addressed these reservations immediately upon meeting the family, as he explained his role: “Maria has been having some school difficulties, and we often find that when our students are struggling in school, their families are struggling at home. I’m here to see if there is any way that I can be helpful to you, since from what I’ve learned so far, you all are living with a lot of stress.”

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All the members of this family attended this session, with the exception of Lupita’s and Roberto’s children, who were involved in after-school activities. What follows is an excerpt from the conversation that followed: dennis: How about we start with Mom. Mrs. Rodriguez, can you tell me a little bit more about how things are with you and your family (gestures to other members)? mother: It goes okay. We do the best we can. We got a lot of people here, but I wanna help my sister’s daughter [referring to Lupita]. She don’t have nowhere to go. Lupita looks nervously at her boyfriend. lupita: We know we are a problem for Mama Carmen, but we don’t have no place else! Roberto don’t have no work right now [Roberto is a seasonal day laborer]. Our kids is in a good school. We don’t wanna change that. roberto: (angrily) I do the best I can! I can’t find no work right now. maria: We don’t have room for all of you! I don’t have no privacy no more. I gotta sleep with Javier and Rosaline and Luis [her cousins] on the floor! That’s not right! And they aren’t my parents (pointing at Lupita and Roberto). They can’t tell me what to do. Lupita and Roberto glance at one another and roll their eyes. lupita: You watch your mouth, little girl. Your mama is sick, and you think you don’t need nobody to mind you, but you’re running the streets and getting into trouble! maria: You’re not our mother! You don’t have no business telling me and Javier what to do. javier: Yeah, you ain’t our mother. Mrs. Rodriguez shakes her head and looks down at the floor. dennis: Whoa, just a sec. Lupita, Maria, Javier, and Roberto start talking over one another. dennis: (whistles): Everybody stop! Take a deep breath! You have a lot of feelings about what’s going on, and I promise everyone will have a chance to talk. But, first we have to make sure everyone can hear everyone else, okay? Think of me as like a referee, a guy who makes sure that only one person talks at a time, so you all can hear one another. Okay? Agree? All but Mrs. Rodriguez nod their heads in agreement. She continues to look at the floor. dennis: Here’s what I’m getting so far. It seems like Mom’s having some problems that keep her from watching out for her kids like she might like and that her

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kids might need. And she wants to help out her sister’s family, but it’s hard. Everyone’s on top of everyone else. And Lupita and Roberto don’t really want to be a burden, but right now, they don’t have a lot of options. And they’re trying to provide some guidance to Maria and Javier, but the kids just want their aunt to butt out (smiles). Does that about sum it up? The members nod. dennis: Here’s the good thing. You guys really seem to want to help each other, but you’re having trouble doing that. I’d like to take a couple of minutes to talk to Mom, Lupita, and Roberto, because there seems to be confusion about who’s in charge.

Dennis is quickly able to see some of the processes that are causing distress and contributing to Maria’s problems in school. These are revealed in Mrs. Rodriguez’s silence, the nonverbal messages between Lupita and Roberto, and Maria’s and Javier’s angry comments. Dennis identifies an important family strength and worldview—their desire to help one another out—but he also introduces in a general way what appears to be a taboo topic: Mrs. Rodriguez’s addiction to alcohol. Dennis attempted to reinforce Mrs. Rodriguez’s role as the matriarch by referring to her as “Mom” and inviting her first to share her views. By saying that he wants to talk to the three adults, he is focusing on the executive system, which seems to be in a state of confusion. Because of the size of their apartment, Dennis cannot meet with the adults independently, as he would like, but as readers will see later, he will have a conversation with them that begins to help them decide, as he says, “who’s in charge.” Table 10.2 summarizes the joining skills.

Table 10.2 Joining Skills: Working with Families Affirming

Seek out and validate strengths

Tracking

Encourage and value narrations of the life stories of the family and its individual members

Creating a therapeutic context

Establish an emotional climate in sessions that enables family members to feel competent, hopeful for change, or both

Monitoring the family’s paradigm (worldview and structure)

• Learn the elements of the family’s worldview, such as values, norms, beliefs, and assumptions about themselves and their world • Learn the elements of the family’s structure of roles, tasks, routines, and goals

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Internal Mediation and Advocacy Methods and Skills

While there is some overlap with the mediation and advocacy skills described in chapter 9, the focus in family work is on the internal structure and processes of the family. To help the members modify maladaptive interpersonal processes, the social worker employs skills that encourage clearer communication and affirmation of relationships. Helping members listen and talk to one another. The worker strives to improve communications between members by helping them ask for, be receptive to, and provide feedback and clarify and qualify what they say. Identify ambiguous communication. When members’ communication is ambivalent or ambiguous, the worker points this out, asking that the members consider what they really intend to say and mean. Encourage self- and other-awareness. When ambiguous communications are identified, the social worker invites family members to consider their motivations and true intentions. Rather than assuming others are mind readers, members must be willing to ask for what they want and say how they feel. This also can include helping members understand the ways in which expectations of one another reflect patterns that existed in their families of origin or (for blended families) their original families of creation. Exploring divergent views. When the members are more honest in their communication with one another, disagreements will inevitably surface. The worker encourages them to express their views and opinions and helps them tolerate their differences. Legitimizing differences in perceptions and behaviors. This skill goes hand in hand with exploring divergent views. The worker validates the family members’ unique and distinctive voices, conveying that everyone is entitled to their opinion. Exploring family myths and secrets. Family myths and secrets are reflected in ambiguous communication and surface as the members more honestly and directly express their points of view. The worker can then help them recognize and relinquish the myths and secrets that undermine their ability to function effectively as a family. Searching for common ground. The worker helps the members find common ground and learn to negotiate solutions to disagreements. This involves teaching them the skills of compromise. Reframing. In searching for common ground and clarifying ambiguous communication, the worker often has to help the members see one another

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and their situations in different ways. Reframing also may include putting a positive connotation onto maladaptive behaviors (e.g., “Your mother’s yelling at you is her way of saying that she loves you and is worried about your staying out all night”). Making supportive demands. The worker will need to directly interrupt maladaptive family processes that have become more or less entrenched. This requires a level of trust between the family and the worker and depends upon the joining skills discussed previously. The worker may have to stop a parent who speaks for a child, or one partner who will not let another speak. This also includes setting and enforcing agreed-upon rules for the members’ interactions in their sessions. Lending support to members and subsystems. Social workers can use their status to support individual members and subsystems whose position in the family needs strengthening. This includes loosening boundaries to promote the members’ connections to one another or strengthening boundaries to promote differentiation. Assigning homework. In addition to interrupting maladaptive patterns that surface in the session, the worker assigns homework to enhance and extend the impact of the work that family members do during a session. Offering reflective comments. Comments by the social worker on the family’s interpersonal processes and structures help members learn about themselves and one another and identify maladaptive communication and relationship patterns, and processes. When family members meet conjointly (i.e., all or some subsystems within the family attend), they are likely to exhibit maladaptive patterns or difficulties in the session through their seating arrangements, who talks and who does not, and the like. This provides the worker with the opportunity to point out patterns and processes as they are occurring. The members receive immediate feedback about what is going on. When a member talks to another member through the worker, the worker instructs the communicator to redirect the communication to the other member. Their growing awareness empowers the family to make the changes needed to resolve the problems they face. We return to Dennis’s initial meeting with the Rodriguez-Guzman-Salazar family. When discussing the following excerpt with his classmates, Dennis acknowledged that he was unsure how far to push the family on Mom’s drinking or how much should be discussed in front of Maria and Javier. He went with his professional judgment that more than likely, everyone knew that Mrs. Rodriguez had a problem with alcohol, even if no one discussed it, and as the older children, Maria and Javier could be party to—but initially not participate in—the adult discussion of responsibilities in the executive system.

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Dennis opens his discussion with the adults with the following: “First, let me remind Maria and Javier that right now, I want to talk to Mom, cousin, and cousin’s boyfriend. I promise—PROMISE—that you guys will get a chance to talk. But right now, I want to hear from them, okay? [The children nod, and Dennis turns to the adults.] I’m not sure if you all have heard the expression, ‘Too many cooks in the kitchen?’ [The adults look puzzled.] Well, it means that there are too many people trying to make decisions all at one time. It means too many people leads to confusion and not getting much done. I’m thinking that’s what it’s like for you all, and this is on top of the stress about all of you living in such a small space and Lupita’s and Roberto’s undocumented status. Does that makes sense to you all?” [Members nodded.] The following conversation then took place: maria: Like I said, they always tell me what to do (pointing at Lupita and Roberto). dennis: Maria, I promise I’m going to give you time before we leave today, but right now, I need to talk to the adults. Maria rolls her eyes, sighs, and covers her face with her hoodie. dennis: Let me ask Lupita. Lupita, you seem to feel the need to step in and look out for Maria and Javier, and your kids as well, right? lupita: Yeah, my kids needs watching over just like my cousins do. I don’t favor nobody I just try to keep them from getting into trouble. Somebody gotta do it! She looks at Roberto, and they roll their eyes. dennis: What was that just now? I saw you two (talking to Lupita and Roberto) share a look. What’s that mean? Lupita and Roberto look at one another and then look down. lupita (after a moment of silence): Mama Carmen been good to me ever since my mother died. She took us in when Roberto lost his job. I don’t mean no disrespect, but she not well. She like her whiskey a little too much. maria and javier (simultaneously): She like her whiskey A LOT! dennis: (to Maria and Javier) Guys, let me talk some more to your cousin and your mom. And then you’ll have a chance. Promise. Okay, so Mom drinks, what, a lot? Too much? All except Mrs. Rodriguez nod their heads in agreement. dennis: (to Mrs. Rodriguez). So, I notice that you didn’t seem to agree. And here we are talking about you. Your family thinks you drink too much. What’s that like for you to hear that? Do you agree? Disagree? mrs. rodriguez: Things is tough for me. I’m not well. I feel better when I have my drinks. Other members start to talk at once.

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dennis: Whoa! One at a time! Maria and Javier, let me hear from Lupita, and then I want to hear from you, okay? Lupita? lupita: Mama Carmen is sick, but mostly she’s sick because she’s drunk! All but Mrs. Rodriguez nod and assert their agreement. roberto: Somebody got to watch out for the children. She don’t do it (pointing at Mrs. Rodriguez). dennis: Maria and Javier, I’m wondering what your thoughts are about your mom’s drinking? Maria and Javier begin yelling at their mother. dennis: (to Maria and Javier) Guys, guys. Your mom needs to hear from you, but she can’t if you’re yelling. And she’s your mom, so I want you to be respectful, okay? maria: Mama, you’re drinking all the time. You don’t make sense and you don’t do nothing but sit and drink. (starts to cry) You got diabetes! You shouldn’t be drinking like that! javier: Mama, you don’t remember things. You just sit there and mumble to yourself. dennis: (to Mrs. Rodriguez) Your children are worried about you, it seems. So are your niece and her boyfriend. (to Maria and Javier) And you might not like it, but they [referring to Lupita and Roberto] are trying to help you out, watch over you. Everybody’s trying to do the right thing, but with Mom’s drinking and everyone living on top of one another, it’s hard. Silence. dennis: Mom, you got a lot of people worried about you, but also angry with you. But I’m thinking the anger is more about the worry. Your children and your niece and Roberto are worried about your health.

In this discussion, Dennis skillfully handles a very difficult situation in which a taboo topic—Mrs. Rodriguez’s drinking—surfaces as he attempts to clarify responsibilities in the executive system. He encourages members to share their concerns about this—including their resentment and other negative emotions—with Mrs. Rodriguez, but he reminds her children that they must do this respectfully because she is their mother. This reinforces her role in the family, even as it becomes clear that Mrs. Rodriguez’s drinking has led her to abdicate her role as parent. Dennis uses reframing to identify strengths: all the family members are concerned about Mrs. Rodriguez, and Lupita and Roberto are trying to help her out with parenting, filling the void created by Mrs. Rodriguez’s drinking. While her family recognizes this as a problem, it is not clear that Mrs. Rodriguez does. In this first session, Dennis is unlikely to resolve or solve the problems of

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Table 10.3 Internal Mediation and Advocacy Skills: Working with Families Help members listen and talk to one another. Identify ambiguous communication. Encourage self- and other-awareness. Explore divergent views. Legitimize differences in perceptions and behaviors. Explore family myths and secrets. Search for common ground. Reframe communications and behaviors. Make supportive demands. Lend support to members and subsystems. Assign homework. Offer reflective comments.

Mrs. Rodriguez’s drinking, the confusion in the executive system, the overcrowding in the family, and the children’s resentment. However, with all the information that he has acquired through observing the members’ interactions and listening to their comments, he can develop a plan that helps them respond to the internal and external stress they are experiencing. This plan will include: • Individual work with Mrs. Rodriguez and, as needed, other family members to address her health issues and addiction to alcohol • Continued work with the adults in the family to work out decision-making in the executive system, and with the entire family to assist members in understanding and accepting changes in this system • Assisting Lupita and Roberto in finding affordable housing and employment and/ or help family members better coordinate their living situation

Table 10.3 summarizes mediating and advocating skills in family work.

PRACTICE ILLUSTRATIONS

Family work need not include all the members in order for more adaptive communication and relationship patterns to develop. In some instances, some members may be unwilling to participate, believing that they are not the problem or that

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change is not needed or not possible. In others, the worker makes the strategic decision that working with one or more subsystems within the family is needed for change to occur. To strengthen a partner system, the worker might see only members of that system. If stressors in that system have spilled over into the executive system, the worker might see its members and others—like children—who are affected by maladaptive patterns like triangulation. Very young family members, like infants and toddlers, or a significantly disabled adult may be unable to participate in a meaningful way, although observing how others react to and interact with such members might be helpful for identifying maladaptive patterns. This is consistent with the assumption that, when possible, having one session with an entire family system is helpful for observing maladaptive processes (Ingram, Cash, Oats, Simpson, & Thompson, 2015; Janzen, Harris, Jordan, & Franklin, 2006). In many instances, we will have no choice but to work with whoever is willing and able to attend sessions. In previous chapters, we have provided numerous examples in which only one or more members of a family have been the “client.” Consistent with systems theory, our assumption is that an improved person:environment fit with one member will affect others in the family system. We concede that such improvement may not be as significant or long lasting as one that involves all members who have been part of and/or affected by maladaptive communication and relationship dynamics. We now provide a number of illustrations of the unique methods and skills that are required when we facilitate sessions with more than one member of a family system. Enhancing a Parent-Child Relationship: Identifying and Helping Family Members Take Next Steps

We have previously stated that clients are unlikely to make complete turnarounds in their maladaptive behaviors all at once. We often must assist them in identifying small steps that they can take toward dealing with and hopefully resolving the life stressors they face. With each successful small step taken, clients are emboldened to take another step. Tyrese Michaels, age 15, had been charged as a juvenile with a carjacking. Because this was his first offense, the court ordered him to attend a youth diversion program and receive counseling rather than be incarcerated in a juvenile correctional facility. After meeting with Tyrese and his father, the social work intern at the program thought that they would benefit from family work. While Tyrese’s involvement in delinquent behavior was the presenting stressor, the worker, Bryce, understood that other stressors they faced contributed to—or even triggered—Tyrese’s actions.

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Mrs. Michaels, the mother of Tyrese and wife of Mr. Michaels, suddenly died of a heart attack. Bryce believed that both father and son needed the opportunity to grieve this sudden and profound loss. Therefore, he proposed that he and his clients work on their grief, as well as helping them successfully respond to the mandate. Using reframing skills, Bryce helped father and son understand the son’s behavior and its association with their loss. Mr. Michaels acknowledged that his wife had been the primary disciplinarian in the family; he also revealed that since her death, he had “lost himself ” in his work. As a result, Tyrese was left to basically raise himself and mourn largely on his own. Mr. Michaels most likely cannot go directly from taking a hands-off approach to discipline to effectively assume this responsibility, particularly given the grief that he is still experiencing. Therefore, Bryce helped Mr. Michaels in individual sessions to assume the parenting responsibilities associated with the executive system in which he was now the sole member. A condition of Tyrese’s participation in the youth diversion program was that he adhere to weeknight and weekend curfews—something that he was refusing to do. Bryce had been meeting solely with Mr. Michaels, reinforcing his role as the executive in the family. In their last session, Bryce had requested Mr. Michaels to complete a homework assignment to decide what curfew times he thought would be reasonable for his son. In their next session, the following exchange occurred: bryce: All right, so you think that requiring Tyrese be in by 9 p.m. on weeknights and by 11 p.m. on weekends was reasonable, and you checked and the court said it was okay, right? Mr. Michaels nods in agreement. bryce: I think there’s more we need to do with the curfew. Like, do you think that you should know where Ty is? Do you want him to check in periodically? Do you want to approve where he goes before he goes there? mr. michaels: Mmm . . . I hadn’t thought about that. I guess I should. Well, I don’t want him hanging with those thugs that got him in trouble in the first place, that’s for sure. bryce: Okay, so that’s a condition of his being out on his own. Are there others? mr. michaels: He’s got a cell phone, so there ain’t no reason why he can’t call me while he is out. So, yeah, that’s another condition. bryce: Great. Now we’re getting somewhere (smiles). How about homework? Even though the program doesn’t require it, you said his grades had dropped. Do you want to address that? Like, homework has to be done before he goes out? mr. michaels: Yep. Hadn’t thought of that either. Homework first, fun second!

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This discussion continued in this same fashion until Mr. Michaels had developed a clear and realistic set of requirements associated with establishing a curfew for his son. This included what he would do should Tyrese violate the curfew: bryce: So, you now have a plan that is reasonable. You and I think it is reasonable, but I can almost guarantee that Tyrese won’t see it that way. He’s probably gotten used to all the freedom he has had. And even though he needs to know you are there to discipline him—he needs that reassurance—I’ll bet he’ll resist and rebel. You need to be prepared for that. mr. michaels: Shit, I don’t need no mouth from that boy. bryce: I get it, you have enough on your plate already don’t you? You miss your wife, you’re worried about your son, and you’re trying to take over for your wife. That’s a lot to tackle all at once. Silence. bryce: What’s going on for you right now, Dad? mr. michaels: It is a lot. Sometimes it feels like too much. bryce: Yeah, I’m sure it does. But I think things are going to be even more stressful if you implement the curfew and Ty ignores it. mr. michaels: You’re right. I know you are. It just seems like a lot to do. bryce: It is, I’m sorry. . . . you’re dealing with a lot.

The student shows much insight as he moves back and forth between Mr. Michaels’s grief and the need for him to assume responsibility for parenting his son. As this conversation continued, Mr. Michaels developed a strategy to deal with his son’s defiance of the curfew should it occur. Bryce reminded him that it would most likely be when Tyrese ignored the curfew, not if he did. The next session involved both father and son. Mr. Michaels needed help to assume an active role in parenting his son, but he also needed help in allowing Tyrese some say in this and other discipline decisions that would affect him. While they continued to grieve the loss of their mother and wife, Bryce helped the father explain his curfew policy to his son and assisted father and son in discussing this: bryce: Okay, so Tyrese, your father has told you what he expects you to do and what your curfew is, and what will happen if you don’t follow it. I’m thinking that’s gotta be hard for you since you’ve been running the streets for the last couple of months. tyrese: It ain’t no big deal. Whatever, man.

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mr. michaels: You show some respect, boy! bryce: (interrupting) Whoa, dad, you’re upset with your son. You want him to be polite, but I’m thinking he has thoughts about what you’ve said, and it’s important you hear them, that the two of you work together. Tyrese, let’s try again, tell your dad what you’re thinking about the curfew and the other things he’s said. tyrese: Well, this is bullshit. I’m 15! I can run my own life! Don’t need my old man to run it for me (looking at Bryce). bryce: Tyrese, talk to your dad, okay, not to me. And you can be pissed, but you gotta talk to him in a way he can hear you. Silence. bryce: Come on, Tyrese. Your dad’s waiting. Tell him your thoughts. tyrese: Okay. Well, Pops, you ain’t been around, and now all of a sudden you wanna be a parent? mr. michaels: You damn right, boy! I’m your father and don’t you forget it! bryce: Okay, hold up. Tyrese is angry, and dad is angry. But what strikes me is that maybe your anger at each other is really hiding a deeper and more painful hurt—that is, that you both lost someone you loved deeply. There’s a hole in your hearts, in your family. And it’s hard to fill that hole.

Bryce skillfully mediates the needs of father and son. He points out an underlying commonality by reframing their anger at one another as the grief that they were both experiencing. As his work with the Michaels family continued, Bryce discovered that Mrs. Michaels had served as a bridge between father and son; she had been the “glue” that held the family together. As a result, father and son were estranged from one another, communicating through Mrs. Michaels and depending upon her to plan social and recreational outings for the family. Therefore, he worked with father and son to strengthen—and in some ways create—a parent-child subsystem through which they could enjoy one another. In the excerpt that follows, he helps father and son identify a common interest that could serve as a basis for their connecting to one another: bryce: So, I’ve gotten the feeling that your mom (to Tyrese), your wife (to Mr. Michaels) kind of held the family together. Now, not only do you miss her, you also don’t really know one another anymore—what you like, what you don’t. It’s like you guys have been living in the same house but have become strangers. Silence.

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bryce: I wonder, when Tyrese was younger, did you guys do stuff together? ‘Guy stuff?’ Fun stuff? tyrese: Well, I played pee-wee football. I sucked, but I played. And my dad would come to my games and would help out coaching. bryce: So, was that fun for you? tyrese: Yeah, me and pops had a good time. bryce: Okay, so tell your dad that. tyrese: Yeah, Pops, we had fun. You was a good coach, even if I was a lousy receiver (smiling). bryce: Was that fun for you, too, dad? mr. michaels: Oh yeah! My boy really did have two left feet (smiling), but we had fun. Laughed a lot. Me and Charlene [his wife] used to love watching them boys play. bryce: So what about now? I know you are still grieving, and it’s hard to even think about having fun. Maybe you might even feel guilty if you have some fun? But I’m thinking that doing something fun together would help you guys with your grief and to get closer to one another. Make sense? Silence. mr. michaels: Yeah. bryce: Tyrese? Make sense to you? tyrese: I guess. bryce: So how about each of you tell me—and each other—what you would like to do, something that interests you?

As this conversation continued, father and son discovered their shared interest in college sports. Bryce then spent time helping them identify an activity that they could undertake in the upcoming week that would allow them to pursue this shared interest. They were then assigned the task of following through with the activity, which was to watch a college basketball game together. Bryce understood that if Mr. Michaels and Tyrese were to be successful in taking the first step toward reestablishing a bond with one another, he would need to help them to do this. By asking father and son to reflect on a time when they enjoyed each other’s company, he was reminding them that there were good times, and there could be good times again. By putting into words the possible guilt that father and son might experience if they were to begin to enjoy one another’s company, Bryce was promoting resilience and giving them permission to move beyond their grief.

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Strengthening a Couple’s Relationship while Helping Them Manage a Life Stressor

Mr. and Mrs. Weiss, a young, white, married couple with no children, sought help from an outpatient mental health clinic. Sonya Weiss, 24 years old, is of Italian descent. She has limited contact with her family of origin as a result of the physical and sexual abuse that she experienced as a child. Until two years ago, Sonya had been a college student studying premed. At the urging of her husband, she dropped out of school due to the stress associated with studying and “making a home” for a husband and herself. Since this time, Sonya has been trying to figure out what she wanted to do with her life and has experienced some bouts of depression. Adam Weiss, age 30, is Jewish. He is employed as an accountant and is completing an undergraduate degree in accounting. He met his wife at work. After several years of dating, they were married. He is the younger of two children, and says he was “spoiled,” always getting what he wanted. The couple sought help for Mrs. Weiss, who became very depressed following an abortion she had two months earlier. In her first session with them, Allie, their social worker, learned that the pregnancy was not planned. Mrs. Weiss stated that she wanted the baby but felt pressured to have an abortion because her husband did not want a child and felt that his wife had “tricked” him by getting pregnant. Mrs. Weiss complained that he always got what he wanted when they disagreed. She felt that her husband was insensitive to her need to have a child and did not care about her. While Mr. Weiss recognized the existence of marital issues, his motivation for coming to the agency was to “get help for my wife, who has a lot of problems.” After he described his wife’s problems, Allie asked for Mrs. Weiss’s perceptions. Sonya said she worried that they were incompatible and probably should not have gotten married in the first place. She feared that her husband married her only because he “felt sorry” for her because of her traumatic childhood. Sonya also complained that her husband had not provided her with any support or sympathy following the abortion, even though she had some significant medical complications. At this point, the following exchange took place: allie: So it seems like what prompted you guys to contact us now is the abortion and how that has affected Sonya? Sonya, you felt pressured to have the abortion and don’t feel supported by Adam? Sonya nods.

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allie: And Adam, you didn’t want to have a child and may have felt pressured to continue with the pregnancy? Adam nods. allie: Okay, so the pregnancy created stress for both of you. Sonya because you wanted a baby, and Adam because you didn’t? Both nod. allie: I’m thinking that some of what is happening now between you—Sonya’s disappointment in and not feeling understood by Adam, and Adam’s feeling pressured by Sonya—isn’t new. Is that possible? sonya: Yes! What Adam wants, Adam gets! adam: That’s not fair! I work my butt off to put food on the table, make a nice home for her. I don’t run around, I don’t go out with friends. I do the best that I can. She’s just gotta stop being so depressed. Sonya begins to cry. allie: It seems like neither of you is happy with the way things are working out for you in your marriage. And it seems the abortion has brought that unhappiness out into the open. When there’s a problem in a marriage, it’s easy for each partner to blame the other. But most of the time, both people contribute to the stress, and both people need to contribute to alleviating it. Silence. allie: Adam, I get the feeling that you just want us to “fix” Sonya. Right? adam: Well, yeah, I guess . . . allie: (to Adam) Does it make some sense to you, though, that maybe the unhappiness that both of you are experiencing is not her, not you, but the two of you? That neither of you are happy with the way things are going? Adam nods his head in agreement. allie: So let me ask the two of you something. Would you like things to be different? Sonya and Adam look at one another. allie: What was that look between you about? Maybe you’re wondering whether things can change? Or whether it’s worth it? sonya: For me, I wonder whether it’s worth it. allie: Adam? adam: Same for me, I guess. Is it worth it? allie: Is it worth it, or is it possible? Maybe that’s the real question. sonya: Yeah, is it possible? That’s what I worry about, that we’re just not compatible. But I’m so sad right now. I don’t want to feel this way! adam: Same for me, I guess. I wonder if it’s possible, but I’d like Sonya to feel better. If she felt better, so would I.

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Initially, the couple’s focus was on the abortion. Sonya felt pressured into having it and hurt that her husband was unable to comfort or support her afterward. Adam believed that the abortion was necessary and felt pressured into becoming a parent. However, Allie introduces to them the idea their current stress may reflect more fundamental tensions in their relationship. Allie will start with the couple’s sense of urgency, which is the impact that the pregnancy and abortion had on them, but as she helps them deal with the current situation, she also will be helping them address the underlying stressors. As the session proceeds, Allie explains to the couple, “I think that the place to start is with the pregnancy and abortion. A pregnancy that Sonya wanted and Adam didn’t, and an abortion that Adam wanted and Sonya didn’t. It seems like that sort of disagreement sums up your relationship.” The following exchange then occurred: Both nod. allie: Let me clear something up first. Adam, I think you said that you felt Sonya tricked you by getting pregnant? adam: She uses birth control, and this has never happened before, so yeah, that’s how it seems to me. She’s been nagging me to get pregnant and I keep saying no. And then all of a sudden she’s pregnant? Seems fishy to me. allie: (to Adam) Have you told her this? Told her what you think? Adam shakes his head no. allie: All right, so perhaps it’s time to do so—please talk to Sonya directly. adam: (to Allie) I just did. I told her what I think. allie: No, you told me—talk to Sonya. Silence. Adam looks awkwardly at the floor. allie: This might seem funny to do it this way, but part of what my job is to help you two to talk and listen to one another. So, how about you try? adam: (turning to Sonya) I told you that I wasn’t ready to have a baby. That we needed to wait until we had some more money. But you got pregnant anyway. allie: (to Sonya) It sounds like Adam thinks you got pregnant on purpose. So I guess I gotta ask. Did you? If you guys are going to work through this, you both need to be honest. sonya: NO. I didn’t trick him— allie: (interrupts) Talk to Adam, Sonya. sonya: (turning to Adam) No, I didn’t trick you! I wouldn’t do that no matter how much I wanted a baby. I think I might have forgotten to take my pills a couple of times but figured it wasn’t a problem. allie: (to Adam) So how does that feel hearing Sonya tell you that? adam: Well, I guess it makes sense. She’s not a liar—

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allie: (interrupts) Talk to Sonya, remember? adam: (to Sonya) I know you’re not a liar. So I guess it was just an accident. Silence. allie: (to Sonya) How about you? Your reactions to what Adam just said? sonya: Well, I’m glad he—(to Adam)—I’m glad you believe me. I wouldn’t do that. But once it happened, I really wanted to have a baby! And you don’t! You don’t want a child ever! allie: So, Sonya thinks that Adam, you never want a child. I guess we need to know whether that’s true or not. Adam? adam: (looking at Allie) Well, that’s not really true. I mean I don’t want a kid now, but that doesn’t mean that I don’t want one ever. allie: (to Adam) How about you explain what you mean to Sonya? And please remember to talk to her, not me. adam: (turning to Sonya) I never said I didn’t want children! I just don’t want one now! We’re just getting started, and I don’t think we’re ready. allie: You don’t think the two of you are ready. Or you’re not ready? Silence. Adam looks down. sonya: See! I knew it! He doesn’t want a child! EVER! allie: Wait a minute, Sonya. Adam did not say that. That’s what you think he’s saying, but he didn’t actually say that. So, again, I think we need to get Adam to clarify. Adam, never a child, or just not now? Silence. adam: Not now. Not right now. It takes a lot to raise a child right. I’m not sure I have what it takes (looks down). allie: (to Adam) You seem to have some feelings about that. Guilt? Sadness? Can you explain your feelings to Sonya? adam: Well, I know she— allie: Adam, talk to Sonya, okay? adam: I know how much you want a child, and I think I do, too. But I think I might suck at it. I know I was spoiled in my family. My mother always wanted a boy, and she spoiled me rotten. I’m not good at sharing. allie: Wow, Adam, that’s a powerful insight. Sonya, how is it hearing that? sonya: I’ve never heard him— allie: (to Sonya) Talk— sonya: I know, talk to Adam. (turns to Adam) You’ve never told me before that you knew how much your mom spoiled you. You can’t do any wrong and your poor sister is, like, left in the dust. allie: (to Sonya) And maybe sometimes you feel that way, too? Like you don’t matter? sonya: Yeah, like I don’t matter. That ‘what Adam wants, Adam gets’.

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The abortion was the catalyst for the Weisses’ dissatisfaction with one another to become unmanageable. In many ways, their focus on the abortion reflects triangulation: the conflict that has surfaced in response to the abortion reflects a more underlying tension. Sonya also is in the role of the identified patient. Both she and her husband want her to be “fixed.” As their conversation continues, it becomes clear that their miscommunication and unspoken expectations for one another have created stress for both of them. Mrs. Weiss has experienced a deep sense of loss about the abortion and is angry with her husband for his detachment and lack of empathy. She interprets Adam’s response as a further sign of his selfishness and lack of concern for her needs. Adam wonders whether his wife tricked him into getting pregnant and feels resentful and boxed into a corner. The worker explores these divergent perceptions, invites each to provide feedback to the other, and persists in reminding them to talk to one another, not to her. She asks clarifying questions and points out contradictions, creating the context for fostering self-awareness, mutual understanding, and open lines of communication. She effectively joins the family system. As the conversation continues, the underlying tensions, as well as Adam’s reservations about his ability to be a good parent, become apparent to all. Allie has the courage to ask the tough questions: Does Adam really want a child or not? Did Sonya trick her husband into getting pregnant? She may have been holding her breath and keeping her fingers crossed when she asked these questions, but she knew that if the sessions were going to be helpful, Adam and Sonya needed to be honest with one another. With Allie’s continued involvement and efforts to help them communicate more effectively with one another, the following issues can be addressed: • Resolving the couple’s reactions to the abortion • Assisting the couple in coming to a decision about having a baby • Helping Sonya manage her depression and consider options related to school

Helping a Couple Deal with a Family Secret: Using a Trauma-Informed Lens

Shavonne, age 35, and Mark, age 34, have been in a committed relationship for 6 years and have one son, Trevor, age 2. Shavonne was sexually abused as a child. The perpetrator was a close family friend who vacationed with her family and attended all family functions. It was during these vacations and holiday celebrations that he would sexually abuse her. The abuse lasted for more than 10 years. Shavonne told her mother on several occasions that she did not like being around

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“Uncle Jack,” but her mother dismissed her concerns, reminding her that he was “like a second father” to her. When she was in her early twenties, Shavonne told her parents about the abuse, and they professed to be shocked and questioned her memories, wondering if she was being influenced by “all the media coverage” about survivors of sexual abuse not remembering it until years later. Because her parents continued to socialize with this individual, Shavonne distanced herself from them and no longer attended any family gatherings that included him. After the birth of her son, at her parents’ insistence, Shavonne began to see her parents more frequently so that they could spend time with their grandson. She was adamant, however, that Jack could not be present. Shavonne previously had been in counseling to deal with her sexual abuse history but felt the need to seek assistance due to increased tension in her relationship with Mark, who was unaware of her history of sexual abuse. Mark questioned why Shavonne did not want to be around her parents, since they were “so nice.” She also worried that Mark was becoming increasingly frustrated with their sexual relationship. Shavonne acknowledged that she had never really enjoyed sex, but since the birth of Trevor, she had been even less interested in being sexually intimate with Mark. Shavonne decided that she wanted Mark to know about her abuse. She and her worker, Carla, agreed that she would invite Mark to attend a session with her, and that in that session, she would disclose her abuse, with the worker’s help if needed. In the session prior to the one excerpted here, Shavonne and Carla discussed how Shavonne would prepare Mark for coming to the session and how she would open the discussion about her sexual abuse when the three of them met. Carla also helped Shavonne consider possible outcomes of her disclosure to Mark, including what she saw as the best case scenario (Mark would be understanding and supportive and not blame her for the abuse) and the worst case scenario (Mark would be angry with her and blame her for the abuse), as a way of preparing her for his reactions. In this excerpt, Carla opens the session with Mark and Shavonne: carla: So, Mark, I suspect you have some questions about why Shavonne wanted you to come today? mark: Yeah, all she would tell me is that she had something important to tell me, but didn’t want to do it alone. She’s not going to divorce me, is she? carla: NO, nothing like that. Promise (smiles). But let me start by saying that my job here is to help Shavonne share with you something that happened to her a long time ago that she thinks you need to know. And I would like to help both

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of you to talk to one another about this. Shavonne, you told me last week that you thought you would have to look away from Mark when you talked to him. Is that still the case? shavonne: Yup. I just can’t look at him. carla: (gently) Shavonne, talk to him, okay, not me? shavonne (turning to Mark): Mark, this is just so hard for me! I just can’t look at you right now, okay? Just let me do this my way, okay? Mark nods his head. carla: Mark, Shavonne is hoping that when she is talking, that you will just listen. And when she is finished, I promise you’ll have plenty of time to ask questions. Shavonne? Shavonne turns away from him, facing Carla. Carla is able to see both Shavonne and Mark as Shavonne discloses her abuse.

As Shavonne and Carla had planned, Shavonne revealed her sexual abuse in detail and also told Mark about her conversations with her parents. When she was finished, Shavonne remained facing Carla, and the following exchange occurred: carla: Shavonne, can you turn around and face Mark yet? Mark, I see that Shavonne’s words had a powerful impact on you. Perhaps you can tell her what you’re thinking? Shavonne turns to Mark. mark: I don’t know what to say! I’m like totally fucked up about this! (to Shavonne) Why didn’t you tell me? You should have told me! Shavonne starts to cry. carla: (to Mark) You’re angry.. . . . At least I’m thinking that’s what Shavonne is thinking? Shavonne nods her head. mark: Well, yeah, I’m her husband! I had a right to know! How could you not tell me (looking at Shavonne)? Shavonne continues to cry. carla: (leaning in toward Mark) This is a lot to take in . . . Mark nods. carla: It makes sense that you’re angry. But, take a minute and think about that anger. Shavonne seems to think you’re angry with her. I’m not sure it’s that simple. Can you tell her what you’re angry about? And, let me say to both of you: whatever it is you’re feeling, you need to be honest, okay? If you two are going to move beyond this, you have to be honest. We’ll work though it together. mark: (turning to Shavonne) I guess I’m angry ’cuz you didn’t tell me. You didn’t trust me or something.

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carla: And that makes you angry because . . .? mark: Well, ’cuz I love her, and I care about her— carla: (gently interrupts) Tell her, not me. mark: I love you, Shavonne. I want to be there for you. Why didn’t you tell me? I just don’t get it. Silence. carla: Shavonne, It seems Mark thinks perhaps you don’t trust him? And I’m thinking perhaps this hurts his feelings? (Mark nods his head.) Can you tell him what made it hard for you to tell him? shavonne: I thought you’d blame me! I am so ashamed about what Jack did to me! I always thought it was my fault. I didn’t want you to think I was a slut or something! Mark gets teary-eyed. carla: (to Mark) Does it make some sense to you why Shavonne might feel this way? That she might worry that you would blame her; like her parents blamed her and she has blamed herself for so long? mark: Yeah, it does, I guess. But I don’t see why she would blame herself. carla: Unfortunately, blaming themselves is really common among survivors like Shavonne. But, how about if you ask her, Mark? Ask Shavonne why she blames herself.

At this point, Mark did ask Shavonne this question, and with Carla’s help, Shavonne was able to say that when her parents didn’t believe her and continued to socialize with Jack, she could not help but think it must have been her fault. This led to the following exchange: mark: What the fuck is that all about! You tell your parents you’re not comfortable around Jack, and they don’t ask about that? Then you finally tell them and they don’t believe you? What the fuck! carla: So, it sounds like that’s another thing that makes you angry? That Shavonne’s parents didn’t support her or believe her? And from what I gather from Shavonne, you’ve always liked her parents, so hearing this, I’m wondering if maybe you’re also angry with yourself? Since, if I understand correctly, you questioned Shavonne as to why she didn’t want to spend time with them. mark: Yeah, like, I should have known. I should have just respected Shavonne on this. Not given her a lot of shit. carla: But how could you have known? Why would you ever think that Shavonne’s parents didn’t do anything when she told them about the abuse? When you didn’t even know about the abuse? Shavonne, how about it? Can you tell Mark what you think about this? Should he have known?

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shavonne: (to Mark) No way, hon. No way you could have known! They do seem nice. They are nice to people. They love Trevor. They just won’t admit what Jack did. And they never will. carla: I think that there’s something we need to make sure of right here and now. And again, you gotta be honest. Mark, do you believe Shavonne? mark: Fuck, yeah! Of course I believe her! (turning to Shavonne) Honey, I believe you. No question! It wasn’t your fault! Jack is a motherfucker! I want to beat his ass!

The rest of this session focused on helping Mark and Shavonne understand and accept one another’s actions: why Shavonne never told Mark; what was behind Mark’s anger; and why Mark should not feel guilty for liking her parents and not understanding why Shavonne did not want to visit them. Carla suggested that each of them identify and exchange questions they had for one another before they left the session, as a way of continuing their discussion. As homework, Carla asked them to answer one another’s questions and helped them decide upon a time and a place when they could do this. Mark and Shavonne agreed to come again as a couple the following week. Carla’s skill at using internal mediation skills was evident as she helped Shavonne and Mark process Shavonne’s disclosure of sexual abuse. She understood that if this couple was going to come to terms with this, as well as Shavonne’s previous unwillingness to tell Mark and her parents’ unwillingness to believe her, she must encourage them to be completely honest. When Carla asked Mark directly if he believed Shavonne and if he blamed her, there was the risk, of course, that he would answer “No” and “Yes” to those questions. As painful as these responses would be for Shavonne, it is far better that Carla reach for his honest reactions—and be in the world of is—than avoid them. At some level, Shavonne would detect her partner’s true feelings, even if he were not forthcoming. In this case, however, it appeared that Mark was able to provide Shavonne with the support and understanding she so desperately needed, given her parents’ unwillingness to do so. At this point, Carla’s role was one of helping this couple talk through their feelings, making sure that what was said was what was heard. In the couple’s second session, Carla first checked in to see how the week had gone for Shavonne and Mark and how their continued conversation went. They both reported that it went well, and each believed that the other was being honest. Shavonne said that she firmly believed that Mark was “on her side,” and Mark confirmed that he understood “completely” why she had never told him before about her abuse, but continued to express regret—but not anger—that

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she felt she could not do this. After some further discussion of this, Carla turned to the topic of the couple’s sexual relationship, since Shavonne previously had indicated that this was a problem for them: carla: You guys are doing really well communicating about Shavonne’s abuse and what that means to you both moving forward. But I’d like to bring up a subject that Shavonne mentioned to me earlier, before, Mark, you joined our session. Sex can be a difficult topic to talk about, but from what I understand, there might be some problems in your sexual relationship? Shavonne, correct me if I am wrong here, but you have worried that Mark is dissatisfied and frustrated sexually, right? Shavonne nods her head. carla: (to Shavonne) And from what I also understand, you have some difficulty being sexually intimate with Mark? Shavonne nods. carla: Again, I know this is a touchy subject, but I think it would be really helpful if we talk this out. Mark, let’s start with you. Shavonne senses some dissatisfaction on your part. Would you agree? mark: Well, yeah, I mean, guys just need it more, right? carla: Well, maybe, but I think the issue is more about the two of you finding the right balance that works for you both. Sometimes this can be harder for survivors and their partners. For survivors, sex can bring on old feelings of powerlessness and guilt and shame. (to Mark) Does this make sense? mark: Sorta. But I’m not that asshole, Jack, right? carla: Shavonne, can you try to explain that to Mark? shavonne: I know you’re not him, but when we’re fooling around and all, I sometimes just go back to what he did. I can’t help it. carla: (to Mark) It’ll help if Shavonne can talk about what she likes and doesn’t like, what feels good and doesn’t. Before, she couldn’t, because you didn’t know what happened. Maybe now she can (turning to Shavonne)? Shavonne nods. carla: Here’s what I’m thinking. You know how we teach kids about good touch and bad touch? Shavonne and Mark nod. carla: Well, the same thing applies here. Some touches might feel good, but others don’t. I think we need to start with helping Shavonne identify what feels good to her and what doesn’t. And then we build on that. And when something doesn’t feel good or safe, Shavonne needs to be able to tell Mark that, and know that Mark will respect that. Does that make sense to you guys? Mark and Shavonne nod.

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The session continued with Carla helping Shavonne identify a “good touch,” which was Mark stroking her arm with his hand, and providing Mark and Shavonne with an opportunity to practice this. She encouraged and helped Shavonne to provide feedback to Mark when his touch began to feel uncomfortable. She also helped Mark understand that Shavonne’s feedback was not criticism of him. Carla then helped the couple plan a time during the upcoming week when they could continue to practice “good touching.” She reminded them, however, that before moving on to another good touch, Shavonne needed to feel totally comfortable and trusting that if she said “Enough” or “Stop,” Mark would respect this. Therefore, she advised against experimenting with a new touch right now. We wish to note that Carla is not a sex therapist, nor does she specialize in working with survivors of sexual abuse. However, her very sensitive exploration of a topic that is taboo in many relationships, but particularly when one partner is a survivor of sexual abuse, exemplifies life-modeled and trauma-informed practice. Carla normalizes and reframes Shavonne’s difficulties with sexual intimacy in a way that both Mark and Shavonne can understand. She continues to use internal advocacy and mediation skills to promote honest discussion between the partners. And she starts small: it is unrealistic to think that Shavonne can go from total discomfort with sexual intimacy to complete comfort. Therefore, she helps Shavonne identify a physical gesture that feels good to her, and then she allows the couple to practice this in the session. Carla assigns homework but also provides a directive: she advises the couple to practice only this one good touch and not go any further. Carla’s exploration with Shavonne and Mark of their problems with sexual intimacy ultimately paved the way for the couple to seek the help of a sex therapist. Carla understood that her responsibility was to help Mark and Shavonne understand the connection between their current problems and Shavonne’s past. She also recognized, however, that she lacked the knowledge and training needed to help them develop a more satisfying and enjoyable sexual relationship. Helping a Child Caught in the Middle and Guiding a Blended Family to Create a New Normal

Family members develop shared, implicit beliefs about themselves and their environment and a worldview that is unique to them. This often creates challenges when two family cultures come together to form a new one. Stefan Layton, age 11, is a sixth grader at a public elementary school. Until recently, he has been a good student who was well liked by teachers and peers.

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Recently, his behavior has changed. Stefan has not been doing his homework and has been talking back to teachers and picking fights with his classmates. When his teacher noticed fresh bruises on Stefan’s arms that he refused to explain, she filed a report with Child Protective Services (CPS), as she was mandated to do. The CPS investigation determined that Stefan was at risk of physical abuse due to the tensions and conflict in the home. His family was referred to the Family Preservation (FP) program at a local outpatient family service agency. FP programs are designed to keep families together and prevent the removal of children by providing intensive, short-term intervention. The student social worker assigned to the case, Antoine, would be meeting with the family in their home once a week for 10 weeks. A second worker would be working with Stefan one on one to help him manage his feelings about the family issues that the agency believed were contributing to his problems in school. Stefan’s mother, Brigette, and father, Byron, divorced 18 months ago. Their divorce was acrimonious, with both demanding full custody of their three children. The judge ruled that they share custody, with the children spending weekdays with their mother and weekends with their father. Brigette has been seeing Clay Moore for eight months and had introduced him to her children on several occasions, and he recently moved in with her and her children. Clay has two children from previous relationships who live with their mothers. He has limited contact with them. Stefan has two biological siblings, Shawna, 7, and Gigi, 5. According to the CPS report, confusion about “who does what” and “who’s in charge” in the Layton-Moore household may be contributing to the problems that Stefan is having in school. The report also indicates that Stefan may be caught in the middle between his biological parents’ ongoing conflicts. Antoine and his field instructor agreed that it would be important to meet with the biological parents first, but also include the mother’s boyfriend at some point. Antoine scheduled a home visit when the children were in school or preschool. The first meeting included only Stefan’s biological parents. After addressing the parents’ reactions to being required to meet with him and ensuring that they understood his role and purpose, the following conversation took place: antoine: As I explained on the phone, Stefan’s problems in school and the bruises his teacher saw led to our involvement with your family. When you met with Ms. Kendall [the CPS worker], she suggested that there’s a lot of tension going on for you two, and that maybe that led you, Mom, to grab Stefan too tightly, which caused the bruising his teacher saw. We want to help you deal with this tension, so that this doesn’t happen again and your children are safe. Make sense?

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brigette: Ever since Clay moved in, that boy’s been a problem. Mouthing off to Clay, pitching fits, not listening to me. byron: No wonder! You’re bringing some strange guy into my home? What the fuck is that about? brigette: It’s not your home! It’s my home—remember? You left the kids and me. And Clay is a good guy— byron: (interrupts) Good guy, my ass. You hardly know him— brigette: (interrupts) I know him just fine. He works hard, he comes home at night. He’s not out messing around with women like you— byron: (interrupts) I told you I gave all that up, stopped drinking. I’m clean— brigette: (talking over Byron) Yeah, right. But you still walked out on me! byron: (yelling) ’Cuz I couldn’t take it no more. All your nagging and suspicions— brigette: (interrupts) I got every right to be suspicious— antoine: (interrupts loudly) Whoa, both of you! Hold up! Clearly, there’s a lot of anger between you two. Like I said, if we’re going to help Stefan, we need to help you work this out. But you can’t work it out if all you do is yell at one another. Mom and Dad glare at one another. antoine: How about each of you takes a deep breath for a minute while I throw out an idea. When parents split up, it’s usually really upsetting to their children. And that’s even truer when there’s a lot of anger. And now there’s a new person—a new guy—in the picture. That’s confusing. I’m thinking maybe Stefan’s telling us that it’s all too much for him. brigette: I have a right to move on with my life! antoine: Oops, sorry. I wasn’t suggesting you didn’t. I’m just saying it’s a lot for a kid to take in. byron: (to Mom) I told you it’s too soon. Why you got to go jump in bed with a new man so soon— brigette: (interrupts) You ain’t my husband anymore. You got no business telling me what to do— antoine: (interrupts) Guys! Again . . . I want to help out here, but I can’t do that if you’re always talking over one another. From what I learned, you both care about Stefan, love him a lot, right? You may not want our help, but you want what’s best for Stefan, right? Both nod their heads. antoine: That’s so important for a kid. To know his parents love him, even if they’re not together. But there is all this anger between you. It’s gotta be really stressful for Stefan—and his siblings, probably. Does that make sense? Both nod their heads.

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antoine: I know this is hard, but I’d like to try to talk a bit about how you two are continuing to parent your kids even though you’re not together anymore. Can you tell me a little bit about this? brigette: Clay and I try to stick to strict rules—he’s a big believer in that—but my kids aren’t having it. That’s ’cuz Byron lets them do whatever they want. He’s the “good” parent, the fun one, and Clay and me are the mean ones. byron: What a crock of shit! They like coming to my apartment because I’m not treating them like they’re prisoners, like your “boyfriend,” Clay. He’s such— brigette: (interrupts) Just shut the fuck up, will you? Clay has good ideas about parenting. He’s— byron: (interrupts) Stop with the bullshit, will you . . . antoine: (interrupts). Hold up! Again! So, you guys disagree about Clay and his role. And that’s something that needs to be worked on. And next time, the four of us will meet to talk this through. But, before that, let’s try again: how are you two—or are you two—working together to continue to parent the kids?

Antoine continued to keep reminding Brigette and Byron not to interrupt one another and helped them focus on the question that he asked them about how they were parenting their children. He learned that Clay had assumed the day-to-day parenting of Stefan and his siblings and that his style was much more authoritarian and rigid than the one adopted by Brigette and Byron. Brigette appeared to appreciate Clay’s more hands-on approach to parenting, while Byron appeared to resent Clay’s presence in his family. The current situation was exacerbating an underlying conflict between Brigette and Byron that revolved around his past drinking and his frequent unexplained absences from home. The session continues: antoine: What’s becoming clear is that there are some deep resentments between you two about Byron’s past drinking, and now with Clay on the scene, that’s just making it worse. Agree? Both nod their heads. antoine: Brigette, it seems like it’s been hard for you to get beyond your anger at Byron for his drinking. You were left alone to do most of the work, almost like a single parent. That, coupled with his affairs, must have been tough for you? And now, you got a guy who’s hands-on, which you appreciate? Brigette nods. antoine: And Byron, it seems like you’re getting you’re act together, but Brigette is still resentful. And you want to be more involved with the kids, but it feels like Clay has taken over?

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Byron nods. antoine: So part of what we have to help you figure out is what role Clay is going to play—if any—in disciplining the children, since that seems to be creating stress for everyone and bringing out the underlying resentment. Next week, I’d like the three of us to meet, but you are the parents, so before we end today, let’s see what you two think about the role that Clay should play. (turning to Byron) You seem resentful. . . . byron: You bet I am! He’s not the kids’ father! He don’t have no right to tell them what to do. He’s got two kids of his own that he don’t even see. antoine: So you wonder why he’s trying to parent your children. Byron nods. antoine: (turning to Brigette) But you welcome Clay’s help. brigette: You bet I do! I felt like I was a single parent ’cuz of Byron’s drinking. Now I got a man who takes an interest in the kids— byron: (yelling) HE AIN’T THEIR FATHER!!! antoine: (to Byron) And that pisses you off. He’s coming in and taking over your role. Byron nods. antoine: (turning to Byron) Now Byron, let me talk to Brigette for a minute, okay? Brigette, can you understand why Byron might be resentful? He’s gotten clean, he wants to be involved with his kids, and now there’s this guy who’s taking over for him, both as a parent and as your partner. brigette: He should have thought of that before he left us. antoine: So, there’s that resentment again about Byron’s drinking and him leaving you and the kids. . . . brigette: Yeah, now I got a man who treats me and the kids right— Byron starts to talk. antoine: Byron, wait just a sec. Just listen for a sec. Brigette, I get that you like having a guy who’s hands-on. But, what do you think it’s like for Stefan? All of a sudden, there’s this new guy in the house, with a whole different set of rules? Silence. brigette: Well, I hadn’t thought about that— byron: (interrupting) Well, you should have! antoine: Byron, just a sec, I’ll come back to you. Promise. Okay? Byron nods. antoine: Brigette, so, if you think about that, about how it must be for Stefan—and his siblings—does that make you think any differently? brigette: Umm, maybe  .  .  . Byron wasn’t around. Clay is, and wants to be involved . . .

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antoine: But? I’m hearing a “but” there. brigette: Maybe it is confusing for the kids. antoine: Is it possible that your involving Clay has more to do with what Byron didn’t do than really needing his help? Silence. brigette: Well, Clay and me, we do see things differently. antoine: Let’s let Byron jump in here. Byron, do you understand why Brigette might have resented your drinking and being an absentee parent? byron: Yeah, I can see that. But that don’t mean— antoine: (interrupts) Hold up, Byron. Just stick with me here. So, you get why Brigette might be resentful. But now you’re clean and now you want to be more involved with your kids. Byron nods. antoine: Brigette has said that maybe her allowing Clay to have such a say in parenting might be about the past resentment. Brigette, are you hearing what Byron is saying here? That he’s clean and he wants to be involved? Like he wants you to give him a chance. Brigitte nods. antoine: Okay (smiling)! That’s great, Brigitte. You’re really trying to understand Byron’s point of view.

This example nicely illustrates the persistence needed when we are helping family members work through and resolve disagreements. Throughout much of this session, Antoine had to forcefully remind Brigitte and Byron not to interrupt one another. His efforts are evident as they began to see how their unresolved resentments contributed to the current stress that the family was experiencing, which was manifested most noticeably in Stefan’s behavior. Antoine’s initially focused his efforts on Brigette and Byron, understanding that, despite their divorce, they remained in the executive system as their children’s parents. Using mediating skills, he encouraged them to share their resentments with one another, while reminding them of what they had in common—the love for their children. Building upon this, Antoine introduced to Brigitte the idea that her reliance on Clay to help parent the children might reflect the unresolved resentment she still held toward Byron. Because Antoine was so effective at mediating the couple’s different points of view, he was able to advocate for Byron having a greater role in parenting his children, in a way that Brigitte could hear. In the remaining seven sessions that Antoine had with this family, including Clay, he helped them negotiate the “new normal” of their blended family. This included

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two sessions with the children, since they needed help in navigating the altered living arrangements, maintaining their relationship with their father, and developing a relationship with their mother’s boyfriend. In the next chapter, we focus on helping groups manage maladaptive processes that undermine their ability to engage in mutual aid and resolve common challenges. Readers will see that many of the practice methods and skills presented in this chapter will apply when we help group members acknowledge and work through maladaptive relationship patterns that undermine their ability to engage in mutual aid.

Helping Group Members with

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Maladaptive Communication and Relationship Patterns

Mutual aid is the primary rationale for the development of group services. Maladaptive processes that create stress for members of a group may emerge at different points in its life course. When these surface, the group becomes blocked from serving as a system of mutual aid, and its members’ efforts to work on agreed-upon life stressors and tasks are undermined.

INTERNAL GROUP FUNCTIONS, STRUCTURES, AND PROCESSES AS STRESSORS

As first discussed in chapter 6, groups universalize individual concerns, reduce isolation, and mitigate stigma. Whether the mutual aid potential is realized depends upon powerful, yet subtle interpersonal processes that are analogous to the family processes discussed in chapter 10. As group members develop a sense of purpose and commonality, they begin to share experiences and concerns. Safe (or at least less threatening) issues are often raised first to test the worker’s and other members’ genuineness and trustworthiness. Through this testing, members develop and reinforce mutual bonds

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with one another and a structure for work, including norms and roles (Gitterman, 2003a). As they relate to one another, they experience a “multiplicity of helping relationships, with all members participating in the helping process, not just the social worker” (Schwartz, 1961, p. 18). The group also can become a microcosm of members’ interpersonal self-presentations, since members’ interactions with one another mirror those that they have with others in their social environment. This allows the members to examine their own adaptive and maladaptive perceptions and behaviors. Through their exchanges with one another, members can develop and practice new interpersonal behaviors and receive immediate feedback from others on their efforts. Groups also have the potential to be a force through which their members act within and influence their environments. Being active in a group and influencing one’s environment enhance a sense of personal, interpersonal, and political empowerment. Stages (Phases) of Group Development

Groups go through phases of development, particularly when they exist over time.1 Different conceptualizations of group phases have been proposed (Garland, Jones, & Kolodny, 1965; Schiller, 1995). In this text, we use BermanRossi’s (1993) five-stage model, which emphasizes the ways in which members’ interactions with one another shape the development of the group as a whole. Initially, the group is nothing more than a collection of individuals who are questioning one another’s trustworthiness and the worker’s authority, competence, and caring. Over time, though, the members’ concerns shift to where—or even whether—they will fit within the group’s structure. As their place within the group’s hierarchy becomes clearer, members turn their attention to how intimate they wish to become with each other. Some members will value closeness, others interpersonal distance, and still others will be more neutral. For mutual aid to prosper, the group members—with the worker’s assistance—must develop interpersonal trust and intimacy. This leads to yet another developmental task for members, which is developing comfort with disagreement and differing points of view. How quickly—or whether—a group moves through phases of development will vary depending upon its length (a one-session group may move quickly and superficially through each phase or not go through every or any phase), its composition (a group that is more heterogeneous may take longer to develop intimacy), and members’ sense of urgency (when urgency is strong, members may move quickly through the phases). While a group will move through phases, these will ebb and flow in response to the interplay of group members and their environments.

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The interplay of two factors, the worker’s authority and members’ interpersonal relationships, “provides much of the driving force of the group experience” (Schwartz, 1971, p. 9). These forces, however, do not always occur in sequential stages. Authority and intimacy themes are present in every group. Sometimes they appear together in the foreground; other times, one theme moves into the foreground and the other recedes into the background. These themes are not fixed or linear, but rather are transactional, and they are significantly influenced by member characteristics, the group purpose and structure, and the agency context. The group’s ability to move from a collection of individuals to a mutual aid system that promotes intimacy and differentiation also is influenced—and can be compromised—by the processes described in this chapter. Table 11.1 summarizes the phases of group development and associated member and worker tasks.

Table 11.1 Phases of Group Development and Associated Tasks Phase I: Preaffiliation Individual and Collective Tasks of the Group • Develop an understanding of the group’s work and the connection between individual need and agency service. • Establish a division of labor. • Establish a structure for work. Tasks and Skills of the Social Worker • Clarify the group’s role and purpose and arrive at a working contract with members. • Provide the initial structure. • Clarify the link between clients’ needs and the agency’s service. • Partialize the clients’ needs. • Reach for feedback. • Tune in and respond directly to indirect messages. • Point out commonalities among members. Phase II: Power and Control Individual and Collective Tasks of the Group • Develop into a mutual aid system.

• Resolve the relationship with the worker so members can deepen their work • Develop a structure for working. Tasks and Skills of the Social Worker • Help the group develop into a mutual aid system. • Help the members develop a structure for working. • Acknowledge challenges to her or his authority so the work can go forward. • Maintain a balance between affective and instrumental tasks. • Encourage the discussion of taboo subjects and difficult feelings. • Point out obstacles to mutual aid. • Point out common ground.

Table 11.1 (continued) Phase III: Intimacy Individual and Collective Tasks of the Group • Develop a sense of cohesiveness for further engagement with group tasks. • Begin to satisfy individual needs. • Invest in the group and increase members’ reliance on each other. Tasks and Skills of the Social Worker • Help the group members balance self-revelations and need for privacy. • Increase the demand for work. • Partialize any problems. • Note recurring themes. • Point out connections between general and specific. • Encourage direct member-to-member communication. • Translate individual problems into group concerns. Phase IV: Differentiation Individual and Collective Tasks of the Group • Build on intimacy to allow differentiation and uniqueness of individuals. • Use the group to work on common tasks as the end is in sight. Tasks and Skills of the Social Worker • Same as in previous phase • Use the connection between specific and general so that gains can be applied to future situations. • In light of coming to the end of the group, clarify the members’ needs, gains, and remaining work. • Reinforce individual and group strengths and adaptive patterns of interacting. Phase V: Separation Individual and Collective Tasks of the Group • Evaluate the work of the group. • Define any remaining work for the members in the group. • Dissolve ties without dissolving what the group has meant to the members. Tasks and Skills of the Social Worker • Evaluate the group’s work. • Define any remaining tasks. • Help the group complete its work. • Focus on the affective and instrumental aspects of ending the group. • Authentically and appropriately use one’s own feelings to help the group members achieve closure. Adapted from Berman-Rossi (1993).

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Sources of Internal Stress in Groups

Not all groups succeed at fostering mutual aid and achieving members’ collective tasks. Some groups never begin, others begin and then disintegrate, and still others reinforce maladaptive behaviors among individual members and the group as a whole. Such maladaptive interpersonal processes often emerge from formational and structural elements. Lack of Consideration of Group Formation Tasks

A common source of internal stress stems from the agency and/or the worker paying insufficient attention to the considerations associated with creating a group that are identified in chapter 6. These include the following: 1. Clarity of the group purpose (help members deal with life transitions, traumas, and environmental stressors). When the members’ needs are too divergent or remain unclear, or the agency’s agenda is inconsistent with the members’ interests, or the social worker’s conception of group purpose is ambiguous, then the members will have difficulty committing to shared tasks and goals. 2. Consistency between the group purpose and group type (educational, resolution of common stressors, behavioral change, social development, task, and/or social action). If the group type does not support the purpose of the group, the members’ ability to meet its purpose is compromised. For example, if members need or desire a group that provides support to them as they grieve the homicide of a loved one (life transitions/trauma) and the group type is educational, they are unlikely to get the help they need. 3. Group composition (degrees of homogeneity and heterogeneity; consideration of the “Noah’s Ark” and “Not the only one” principles). Overly homogeneous groups may lack vitality, while groups that are too heterogeneous may lack stability because members with limited interests or concerns in common find it difficult to relate to one another. When one member differs in a meaningful way from others, this may reinforce feelings of isolation and differentness. 4. Group size. Groups that are too large cannot provide sufficient opportunities for individual participation and intimacy; on the other hand, groups that are too small can make excessive demands for intimacy. 5. Group structure (open or closed membership; time-limited or open-ended). Openended groups with fluctuating membership provide more opportunity for clients who need group services to receive them. However, they may develop two

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problems: their members lose their original sense of purpose and vitality, and groups that constantly add new members never move beyond the early phase of development. Members may need the intimacy that is provided in groups with a defined time frame and closed membership. 6. Leadership (single leadership or coleadership). While students—and many inexperienced group workers—prefer coleadership, this adds a complex dynamic to the group process; namely, the workers struggle to synchronize their interventions and to cope with role ambiguity, competitiveness, and discrepant interventions. 7. Organizational sanctions and supports. Inattention to formal and informal organizational structures and processes accounts for many group difficulties. Without vertical, administrative approval and horizontal staff involvement, the worker walks on eggshells. 8. Consistency between group purpose, type, structure, and expectations. The expectations that guide members’ interactions with one another should be reflective and supportive of the group’s purpose. For example, if a group focuses on helping members manage their anger, but members are prohibited from expressing anger, the group’s purpose cannot be achieved.

These considerations are interdependent; together, they promote the mutual aid potential in a group. When insufficient attention is paid to one or more of them, this potential is unlikely to be realized, while the risk of dropout and member dissatisfaction and lack of interest increases. One of the more common problems that we see among our students occurs when they are tasked with taking over or joining a group that their agency already is offering. With little or no input into how the group is formulated, structured, or facilitated, students often experience firsthand violations of one or more of the eight considerations and the negative consequences that these have. Consider the following scenarios: Taylor works in a 60-day shelter for domestic violence victims. The shelter offers a structured group for its residents with a focus on educating members about intimate partner violence. The group’s curriculum runs for six sessions and then starts over. Residents are required to attend. Taylor described members’ lack of interest in the group and reluctance to attend. She attributed this to the fact that many members had gone through more than one cycle of the curriculum and were bored, while others joined in the middle of the cycle and were confused. Jim joined an anger management group being offered at his placement, a residential facility for male juvenile offenders. The group was required for any resident whose

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offense involved assault. There were three group leaders—including Jim—and two “safety” staff, who monitored the members’ behavior. Jim noted that any time a member became angry, he was escorted out of the group by one of the safety staff, which led him to question how the group could help members with anger if they were not allowed to get angry. Jim also noted that in many instances, there were more staff than members in attendance. Shannon participated in an art activity group for young children in foster care that was supposed to assist them with feelings associated with their separation from their parents. The group consisted of 12 children between the ages of 5 and 8. Because the 16 interns at the agency were all required to have a group experience, the agency director decided to have 4 interns take turns, so that each foursome led the group once a month. Shannon observed that the members and leaders seemed confused and the group lacked focus. She surmised that this might be the result of the leaders never talking to one another, so no group of leaders knew what the others had previously done.

While the problem in each of these groups was different, the result was the same: mutual aid was largely nonexistent, and members lacked interest in and did not benefit from participation. One or more of the considerations that previously have been identified were ignored or violated. Taylor’s group did not reflect the realities of the setting in which it were being offered, resulting in redundancy of content and confusion and boredom among members. The purpose of Jim’s group—anger management—was undermined by the staff ’s need to overcontrol the group. The presence of safety staff was not in and of itself problematic. Handled correctly, their presence could have served as reassurance to members and group leaders alike that they were safe. However, they were used to enforce compliance with agency rules, which negated the very purpose of the group. And Shannon’s group suffered from the adage, “Too many cooks in the kitchen.” A group comprised of children, like this one, could benefit from additional leaders, but this one had 16 student leaders, each of whom had their own ideas about how to facilitate the group and none of whom talked to one another. Lack of Understanding of Mutual Aid

Just because an agency offers a group service does not mean that it will be helpful and foster mutual aid (Gitterman, 2006, 2017) or provide members with an opportunity to work collectively on common life stressors, as the following examples indicate:

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Warren, a veteran, is placed in an outpatient mental health clinic at a Veterans Administration hospital. He is assigned to colead an ongoing support group for veterans struggling with posttraumatic stress disorder (PTSD). His coleader is his field instructor. Prior to his joining the group, Warren and his field instructor had only briefly discussed his role, and his field instructor, Ken, assured him, “You’ll do fine, since you’re a vet, too.” In Warren’s first session with the group, Ken introduced him by saying simply, “Folks, this is Warren. He is going to be joining our group. He’s a veteran himself, so I’m sure he will be a valuable member.” This session’s focus was “Caring for yourself,” and each of the 10 members took turns identifying what they did to care for themselves. When it became Warren’s turn, he reported later that he felt put on the spot: “I wasn’t sure how I was supposed to answer. Ken invited everyone to share their ways of coping, but didn’t share his own, but I think he wanted me to share. I didn’t have problems with PTSD, so I really couldn’t relate. I just said something lame like, ‘I listen to music.’ ” In subsequent weeks, Warren reported that the members seemed uninterested and absences became more common. When he asked his field instructor about these problems, Ken replied, “Sometimes the members just need a break.” While the group continued for the rest of Warren’s placement—another 10 weeks—the absences continued and members seemed bored. Jorge was placed in a residential treatment facility for adolescents. On his two days in his field placement, he facilitated the daily “rap group,” which focused on resolving the inevitable tensions and disputes that surfaced among members of the unit in which they were housed. The group included all residents of the unit at any particular time. When Jorge returned to his placement after the weekend, his field instructor informed him that a resident from another unit had committed suicide and the facility was in an “uproar.” As a result, his field instructor advised him not to bring this up in the group, since this would just upset the members further. While Jorge questioned it, he adhered to his field instructor’s advice. When he met with the members, he described the session as “chaotic,” and he had to call for help from support staff to quell the fighting that ensued. The same thing occurred for the next several sessions. Jorge complained that he felt like he was being “dishonest” with his group by not talking about the suicide, but he did not think he could go against the advice of his field instructor.

Unfortunately, the problems illustrated in these examples are quite common. The lack of clarity around Warren’s role undermined the group’s ability and willingness to work on the common stressors they shared as a result of their combat experiences. Instead of focusing on this, members were preoccupied with asking themselves, “Who is this guy?”

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Jorge was correct; the members of his residents group needed—desperately— to talk about the suicide of a fellow resident. The more he prevented members from talking about this, the more of a taboo subject—and an elephant in the room—the suicide became. The members were conveying their distress about this through their actions. Rather than addressing this, Jorge—once again following his field instructor’s advice—ended the sessions, which served only to deepen their upset. Misuse of Rules and Misunderstanding of Norms

In chapter 7, we suggested that an important task in the beginning phase of working with families and groups is to establish guidelines for how members will work together to accomplish their collective tasks. Guidelines will vary depending upon a group’s purpose and member characteristics. They typically address issues such as communication (one member talks at a time; no one talks for anyone else), affective expression and safety (anger must be expressed in words, not through violence), attendance (members should let the worker know if they need to miss or arrive late to a session), and confidentiality (what is discussed in the group stays in the group). The worker may determine expectations for members prior to the group’s start and explain them to members in the first session. These should be limited to behaviors that actually threaten the group’s survival (running out of the room, physical fighting). Otherwise, members may decide—with the worker’s guidance—how they plan to work together. In many instances, expectations are decided upon using both strategies. However they are created, guidelines are needed to help members accomplish their work together. In members’ earliest interactions, clear expectations (particularly regarding safety and how they will interact with one another) are reassuring, provide a sense of predictability, and orient them to the work the members and the worker will do together. Over time, as members’ needs change and the group evolves, expectations may need to change in response. Therefore, the worker helps members establish a structure for work that provides consistency but also allows changes in the way they relate to and behave with one another, the worker, and the external environment. Flexible expectations allow the group to respond to changing circumstances, but also provide continuity. The group’s work is undermined when expectations are nonexistent, constantly in flux, or ambiguous, since members are constantly testing to determine what is expected of themselves and others. A lack of structure denies members the sense of collective identity and support that comes from shared expectations.

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When guidelines become rules that members must adhere to, this undermines their ability to accomplish their work together. Spontaneous and genuine interactions are limited or nonexistent, and members’ individuality and autonomy are discouraged. Rigid adherence can contradict the very purpose of the group, as reflected in the experience of Jim’s anger management group. Even though managing anger was the group’s purpose, any time a member actually became angry, he was escorted out of the group. Rather than prohibiting displays of anger, a more helpful guideline would have been one that clarified what was allowed and what was not. For example, members can get angry, but they cannot hurt one another or themselves. Even when expectations are flexibly applied, there will be times when they will be violated. When violations are responded to punitively, this further undermines the members’ ability to work together. For example, in a young adult parents’ group, one member, Julia, arrived to the group meeting smelling of alcohol. Other group members angrily confronted her, since she had violated a group expectation that members must be working on being good parents by remaining sober. Members desired to punish her for violating the expectation of sobriety by asking her to leave the session. Instead, with the worker’s help, members considered not only what made Julia “slip,” but also how come they were so ready to punish her for it. It became clear to all that Julia’s drinking was threatening because they worried that they too might slip. Mutual aid also is compromised when group norms are inconsistent with the group’s purpose and work. Group guidelines are explicitly stated, while norms are expectations that inevitably arise out of members’ ongoing interactions with one another. Group norms regulate how members relate to one another and define what is acceptable and what is not. If a group is going to accomplish its work, explicit expectations and group norms must parallel and complement one another. Problems arise when this is not the case—when the norms that actually guide members’ interactions are inconsistent with the ones that promote mutual aid. In these instances, members’ interactions will reflect the norms that have naturally developed, not the guidelines that have been established. Consider the following examples: Moira was working with a group of high school students who had been affected by violence, including witnessing domestic abuse or losing loved ones to homicide. The group was designed to provide members with a place to talk about and grieve their losses and promote resilience and feelings of safety. An important group expectation was that members talk honestly with and be respectful of one another. After some

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initial reluctance to talk openly, two members began to talk about their fears and sadness. In response, other members changed the subject or talked over the members. In time, Moira requested help from her field instructor because she was finding it “impossible to get members to talk about their feelings.”

Moira had established an expectation at the outset of the group that was consistent with its purpose: members were encouraged to talk openly and honestly with one another to help them cope with the feelings they were experiencing as a result of their exposure to violence. Yet when two members actually did begin to share their feelings, others failed to live up to this expectation. Over time, the norm of the group became to talk about anything other than the very reason members were there. This norm reflected members’ reluctance to share such painful feelings with peers. If the expectation of honest discussion was going to guide the group, Moira needed to discuss the reasons for members’ avoidance when it surfaced. This required her to revisit with members the way they were working together, as we discuss later in this chapter. Tyrone facilitated a group in a men’s prison that focused on preparing members for reentry into the community, including job skills and literacy training and preparing for job interviews. The group included a presentation by Tyrone at the beginning of each session, followed by discussion. Tyrone expressed frustration that he “had lost control” of the group. Members kidded and talked among themselves and treated the group “like a joke.”

While Tyrone had explained to members that he would be “teaching” them skills that would help them to adapt to life outside prison, he had not established any guidelines for members’ behavior and interactions, nor had he clarified how the group would be helpful to them. When discussing this group in class, he realized that he assumed members would know how to act, since it was “a class.” What Tyrone failed to appreciate was that he was facilitating a group, not just teaching a class. The benefits of his group could be derived both from the information Tyrone presented to members and from members’ support of one another during such a pivotal moment in their lives. Rather than helping the men develop a structure for work, Tyrone allowed them to develop their own structure—one that prevented them from benefiting either from his presentations or from the support they could have provided to one another. The norm of the group was essentially a free-for-all discussion.

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Misunderstanding and Misuse of Group Curriculum

Social workers increasingly rely upon manuals or preexisting curricula to facilitate groups with an educational focus. In some instances, this is the result of research protocols evaluating the efficacy of a particular group work intervention. In many others, however, workers value the structure and guidance that a manual provides. A predetermined curriculum can provide social workers— particularly new and less experienced ones—with helpful ideas about topics to cover and how to cover them. Problems arise when a group is driven by the curriculum rather than by members’ needs and concerns and their genuine and spontaneous interactions with one another. When the curriculum takes precedence, mutual aid is stifled or nonexistent. Consider the following example: Adele was placed in an early childhood center for special needs children and asked to form an educational group for parents with children on the autism spectrum. She relied upon a curriculum designed to help parents understand and learn how to respond to the very challenging needs of their children. Topics focused on coping with the life challenges of supporting, educating and caring for a child with pervasive developmental challenges. Both Adele and the group members became dependent upon the curriculum and the distributed materials. This resulted in a passivity that limited members’ involvement with and ability to help each other. In the fourth meeting, a member tearfully recounted a painful encounter that she had had with a family member, in which the family member said that her child would “never be normal” and questioned why the parent was “even trying” to work with him. Adele expressed her concern for the mother’s experience, but then she continued with the designated “lecture” for the day.

In supervision, Adele noted that after this parent’s disclosure, the members lost interest in the topic and seemed bored and distracted for the remainder of the session. With her field instructor’s help, Adele realized that her reliance on the curriculum to the exclusion of members’ thoughts, feelings, and reactions to what she presented reflected her worry about what would happen if she did not maintain control through her presentations. She also came to understand that this particular member was letting her know that she—and no doubt others in the group—needed to talk about the emotional impact that having a child diagnosed with autism had on her. Adele also understood that it was the members of the group themselves—not she—who were in the best position to respond to

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Table 11.2 Worker Contributions to Internal Stress in Groups • Lack of consideration of formation tasks • Lack of understanding of mutual aid • Misuse of rules and misunderstanding of norms • Misunderstanding and misuse of group curricula

this need. Table 11.2 summarizes sources of internal stress in groups that might come from the social worker. Behavioral Expressions of Internal Group Difficulties

Maladaptive interpersonal patterns in groups are often manifested in the behavior of individual members or subgroups of members and the reactions of others to those behaviors. These processes may be experienced as stressful by members, but they serve an unrecognized function: maintaining the group’s equilibrium. Member Roles

Group norms define how members interact with one another, as well as clarify behavioral expectations for individual members that are reflected in the roles that members assume. All participants in groups are members, but there will be variations in how each person plays that role. Some members may be more silent, while others are much more vocal. Some members will emerge as internal leaders, while others play the more passive role of follower. Some members might be comedians, and others might be deep thinkers. The variations in how members participate in a group contribute to its vitality and allows members to engage authentically with one another. Flexibility in role assignment and performance promotes individuality and autonomy. When member roles become static, members become locked into behavior that compromises their ability to benefit from the group and the group’s ability to do its work. The silent member. Silence can provide a member with a powerful—yet distracting—status in the group. Others may wonder what the person is thinking and if they are being judged. This ambiguity and uncertainty can lead to both member and worker discomfort: In Josef ’s music and movement group for seniors, one member, Laverne, sat apart from the group circle. While other members engaged in discussion of the memories

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they associated with the music or chatted while exercising, Laverne remained silent and still. Josef observed that as the group progressed, Laverne seemed even more removed from the group, and he sensed that other members wondered about her.

With each week that passed in which Laverne sat in silence, it became harder and harder for her to speak up or engage with other members. With the help of his field instructor, Josef realized that Laverne’s role as a silent member prevented her from being able to benefit from the group and served as a source of distraction to other members, who likely were asking, “Who is this woman, and why is she here?” To be helpful to the group and to Laverne, Josef needed to understand—and help members understand—the meaning of her silence, as well as help her become more connected to them. The monopolizer. In monopolism, one member dominates the group’s time and attention. This often reflects that member’s anxiety and need for attention and validation. Other group members may tolerate and even encourage such communication because monopolist behavior protects them from self-disclosure and personal involvement, even as they resent the individual’s domination. Monopolist behavior has negative consequences for all group members, including the monopolizer. Instead of focusing on their collective work, members focus—often with irritation—on the monopolizer. Note this example: In a day treatment program, a new worker was assigned to an adult group (ages 27–45) composed of members living with chronic mental illness. The current theme was dealing with parents and agency staff members. The members felt that they were not being treated as adults, despite their chronological age. Mr. Marcotti dominated group interactions. While he was quiet and withdrawn in the program and in individual sessions, in the group he was the “talker.” The group and the worker could depend on him to keep the session going. The group helped Mr. Marcotti learn to assert himself, and he realized how good it felt to talk and have the attention of others. However, the worker began to view the monopolization as a hindrance to the group’s overall growth and tried to limit Mr. Marcotti’s participation. The worker also realized that other members were becoming irritated with his constant talking. The client experienced the worker’s efforts as discrediting his role and fought to hold on to it, which was reinforced by the other members. The worker recorded the following exchange: Mr. Marcotti was talking for a period of time about his sister’s death. I stated that it is very painful to lose a family member, and inquired if anyone else experienced it.

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ms. raines: I had a cousin who died last year and I felt sad . . . mr. marcotti: (interrupting) I didn’t even know my sister was sick. social worker: What do you mean? mr. marcotti: Well my mom told me one day that my sister was in the hospital, and then the next day she died. social worker: This is a very painful experience for you, but could you hold it until Ms. Raines finishes? mr. marcotti: Yeah, I guess so. ms. raines: Well, Mr. Marcotti can keep talking—I can wait. social worker: I think it would be a good idea if you each had a chance to talk and if we waited for one person to finish before another starts. What does each of you think about this? The members nodded in agreement but remained silent. ms. satzman: One time I told my mother I didn’t want to have my hair cut and I would tell her when I did, but she didn’t even listen to me. social worker: You sound like you were very frustrated, and possibly annoyed, because your opinion wasn’t respected. ms. satzman: That’s right. I don’t see why my mother doesn’t ever listen to me. I’m not dumb, you know. mr. marcotti: Yeah, my mom didn’t even tell me when my sister was sick and put into the hospital. social worker: Uh huh, I see. So, Ms. Satzman, you are saying that you would be like to be treated like everyone else. ms. satzman: Yeah . . . mr. marcotti: (interrupts) I don’t know why my mom didn’t tell me that my sister was sick. I have a right to know what’s going on too. social worker: It seems you both are upset about not being treated like adults. Has anyone else had similar experiences? mr. marcotti: I have another experience of when I wasn’t listened to. One time . . . He continued on for a while longer until I interrupted him. social worker: Mr. Marcotti, I appreciate your contributions, but maybe we could hear from other members and then we’ll get back to you, okay? The other members remained silent.

In supervision, the worker expressed understandable frustration with Mr. Marcotti’s tendency to dominate the group’s time and conversation. While the worker attempted to end his monologues and interruptions, he failed to appreciate the function that Mr. Marcotti’s monopolizing behavior served: it allowed other members to stay silent and avoid participating in the discussion.

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To effectively address this dynamic, the worker needed to address Mr. Marcotti’s behavior and the reasons why members condoned and accepted it. Monopolist represent a maladaptive group pattern rather than simply the personality characteristic of an individual member. The scapegoat. The role of scapegoat, like other roles, serves a function for the group. As they focus on the scapegoat’s vulnerabilities, other group members deflect from dealing with their own life stressors. At the group level, focusing negative attention on one member promotes solidarity, but at the expense of the scapegoat. Scapegoating also provides members with a way of focusing attention on another person, rather than on themselves and their own vulnerabilities. In certain situations, the scapegoated member contributes to the maladaptive process by calling attention to themselves. While the scapegoat may receive some benefit from this role, in the form of attention, the attention is negative and serves to distance the scapegoat from the rest of the group. Unfortunately, scapegoated members often find themselves in a role that is familiar to them: their behavior in the group mirrors their behavior in social relationships outside of it. The following presents a good example of this phenomenon: In a group of middle-schoolers, there was one, lone Latina member, who was scapegoated. This resulted both from her being “the only” Latina and how she reacted to members’ taunts. She provoked further ridicule by making childish comments, talking in an immature voice, and behaving in ways that further irritated other members. Her responses to the members’ provocations served only to reinforce her role as the scapegoat.

Scapegoating controls and suppresses important issues by diverting attention from the group’s work. When group norms permit members to exploit one member, all the members become vulnerable to the guilt associated with having engaged in scapegoating and anxiety associated with worrying that they also could be targeted. The scapegoated individual internalizes the negative perceptions of others. Rather than experiencing the validation provided by mutual aid, the scapegoated individual experiences a sense of isolation and aloneness: Frank is an intellectually challenged member of a “truancy group” for adolescent males in high school. He exhibits poor self-control and occasionally engages in immature and childish clowning. In an early meeting, Stanley was describing how the teacher makes school impossible for him: “The work is too hard, and the teacher calls on me when I don’t know the answers.” As all the boys began to laugh, another boy, Angelo, asked Frank, “What’re you laughing about?” The worker asked if anyone else had a similar experience. Frank replied, “Yeah, in dancing class, all the

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kids laugh at me.” He then demonstrated his dancing and explained that the teacher made him stand in the corner because he made mistakes. Another member, Billy, said, “Frank, you are so damn stupid anyway.” Angelo added, “You don’t even know how to read, write, or do math.” All the boys laughed and joined in attacking Frank.

Frank performs a critical function for the group, permitting members to evade necessary work on painful life stressors and to displace frustration and anger. The teens manage their hostilities by focusing their attention on one member, who provides the group with comic relief. For Frank, the positive consequence is the momentary attention he receives, but it comes at a price: it reinforces for Frank his “differentness” from the other members. The fact that both Frank and the group benefit from the scapegoating underscores the transactional nature of this dynamic. Thus, the social worker must understand not only why scapegoating is necessary for the group, but also what leads Frank, the scapegoat, to invite and accept this negative attention. Scapegoating is not always a transactional phenomenon. The scapegoat may be the most vulnerable member of the group, be different from the others in some significant way, or represents characteristics from which others seek to distance themselves. For example, the sole female or person of color in an adult substance abuse recovery group may be the focus of negative attention due to their differentness and therefore their vulnerability. In such cases, the worker primarily focuses on group members’ behaviors rather than the scapegoated member’s contribution to the process. Consider the following examples: Members of a group for adolescent males teased and made fun of one member who behaved in a way that they associated with “being gay” (he was not interested in or good at sports; he liked the arts; and he spoke in a soft, high-pitched voice). As adolescents, members were struggling with their own sexuality, and this individual’s behaviors were threatening to them. In an assisted living facility for aged individuals, the least lucid member evoked hostility from the others. She represented a safe target for the displacement of members’ feelings of despair, impotence, confusion, and anger. The disoriented member’s inability to stand up for herself frightened the other members and triggered further scapegoating of her.

In both situations, the scapegoated member’s only contribution to the process consists of personal traits that other members find threatening or easy to target to manage their own anxiety. The worker protects the weakest member by making supportive demands on the other members to examine how their

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behaviors undermine the processes of mutual aid and the group’s purpose. Consistent with the intervention when scapegoating reflects a transactional process, we help members find common ground rather than side with the scapegoat and accuse others of being “unfair.” The indigenous leader. Often, a member emerges as a “spokesperson” for the group. This individual often voices the concerns that others are experiencing and can be a valuable source of information for the worker. Difficulties occur when the group worker vies with the indigenous leader for control of the group, as in this situation: The worker facilitated a support group for parents who were found to be at risk of abusing their children. One member, Leigh, was a vocal and dominant member of the group. Others looked up to her and respected her opinions. When the worker pointed out a connection between parents’ anger at their children and experiences they had had in their own childhoods, Leigh angrily suggested that “there was no point” in talking about the past, and members needed to focus on how to discipline their children. The other members nodded their heads in agreement and changed the subject.

In supervision, the worker expressed her frustration with the group and anger at Leigh, believing that Leigh was “preventing” the group from doing its work. What she failed to see was that Leigh was actually speaking for the group, conveying their fears about talking about painful experiences they had had as children. Another problem with the indigenous leader role emerges when the group relies on this person to do all the work: Roberta facilitated a group for victims of interpersonal violence living in a shelter. Most of the seven women were passive participants in the group, only responding to questions that Roberta posed. In contrast, Daniella was a very vocal and active group member; others looked up and deferred to her. When Daniella abruptly left the group to return to her husband, Roberta expressed frustration because group members were now silent and appeared disengaged.

Roberta realized that Daniella’s role as an internal leader kept other members from fully participating in and benefiting from the group. Members—and Roberta as well—depended on her to do all the work. Roberta also realized that being locked into the role of internal leader ultimately was not helpful to Daniella. She was expected to always be “on,” which placed an undue burden on her and prevented her from receiving support from the others. Daniella’s role as an

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outspoken leader also served a function for the group: it allowed other members to avoid talking about their experiences as victims of interpersonal violence. Subgroups and alliances. At times, group members ally with one another based upon perceived similarities or when faced with differences of opinion or perspectives. These alliances, a dynamic known as factionalism, can compromise mutual aid when they become a fixed pattern whereby some members are included and others excluded. Membership in the clique may provide individuals with a sense of identity and belonging, but it does so at the expense of those not a part of that subgroup. Subgroup members may compete for the leader’s attention and for improved status for themselves, at the cost of unaffiliated members, undermining their status and security and the group’s overall cohesiveness, as the following example illustrates: A coed group of eight children was composed of natural subgroups of fourth and fifth graders who knew each other from their classes. Two subgroups also formed based upon gender. While the group’s purpose was to deal with peer tensions, the members’ alliances prevented this focus from being realized. The worker records one session in which the factionalism was clearly evident, as was his frustration. A fourth grader, Jeannie, is speaking, but is interrupted by three fifth grade girls, Ann, Barbara, and Tracy, who begin to tease and fool around with one another: richard: [to the fifth grade girls] Shut up! tracy: You shut up, you big fatso!Barbara and Ann began to laugh. worker: (looking at the three girls) Jeannie was talking and it’s rude to interrupt. Remember our rule? richard: (looking at the three older girls) See, I told you, you shouldn’t be talking. All three girls told him to shut up and continued to call him names, laughing at him. worker: (to the three older girls) Remember there’s no name-calling in this group! tracy: [to the worker] Richard started it. He’s such an idiot. The three older girls continued to laugh. frankie: Knock it off. You’re being so rude! worker: Hey, guys, be quiet and listen to Jeannie, okay? Jeannie, go ahead with what you were saying. The three older girls began to giggle. worker: (looking at them angrily) I’m really tired of your being rude to other members. The three older girls tried to suppress their smiles, and Tracy pulled her chair in close, with exaggerated interest in what Jeannie was saying.

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worker: (looking sternly at Tracy) Tracy . . . Tracy moved her chair back with a smile, while Barbara and Ann laughed. Jeannie went on to describe an argument she had with a classmate and how she tried to hold her temper. worker: (nodding) Anyone else have a similar experience? zoe [a fourth grader]: Me and my mom got in a huge fight ’cuz I didn’t clean up my room and I told her I hated her. Frankie was drawing something, and his body was sideways to the group. Richard was looking over his shoulder, and Billy was also drawing, but was facing the group. frankie: (looking up from his drawing) Me and my brother starting smacking each other ’cuz he was messing with my stuff. worker: So a couple of you guys have had gotten into fights . . . Tracy, Ann, and Barbara began giggling loudly, making fun of Frankie’s drawing. worker (to the three older girls): Please be quiet! ann (loudly): Frankie’s drawing, and he wouldn’t show it to us. worker: Frankie, could you show us your drawing? Frankie shook his head no. tracy, ann, and barbara (simultaneously): Show us your drawing! Jeannie and Zoe whispered to each other. worker: Guys, guys, please be quiet. Frankie and Billy, stop drawing and turn around so you guys can be with the group. Frankie and Billy reluctantly turned around while the older girls taunted them and giggled. frankie: SHUT UP! billy: Yeah, shut up! The three older girls became very angry, Tracy turned her chair around, and Barbara and Ann followed. worker: COME ON, guys, please turn your chairs around. The girls ignored the request. frankie, billy, and richard (simultaneously): Turn a-round, turn a-round, turn a-round. Zoe and Jeannie began giggling. worker: All right then! Meeting’s over for today! Until you guys can start acting mature in this group and participate, I don’t want you to come back. Group members froze and everyone became quiet, and the three older girls immediately turned their chairs back around, saying they would be good now. worker: Please leave, and we’ll discuss this next week.

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Table 11.3 Behavioral Manifestations of Maladaptive Group Processes • Individual member roles: 0 The silent member 0 The monopolizer 0 The scapegoat 0 The internal leader 0 Subgrouping and alliances

This scenario may be every student’s nightmare: the worker lost complete control of the group. Members’ difficulty maintaining friendships was on full display as they jockeyed for position, aligning themselves with others with whom they felt most comfortable. The natural alliances in this group based upon gender and age resulted in subgrouping that obscured members’ underlying commonality. Rather than reaching for members’ underlying common bond, the worker relied upon inflexible group rules to shut members down, blocking the very behaviors with which they needed help. Table 11.3 summarizes behavioral manifestations of maladaptive group processes.

SOCIAL WORK FUNCTION, MODALITY, METHODS, AND SKILLS The Social Worker and Maladaptive Group Processes

The most effective way to address maladaptive group processes is to prevent them from occurring in the first place. This requires the worker to attend to the eight considerations presented at the outset of this chapter. The social work function is to help members communicate openly and directly as they work on their common life stressors and develop greater mutuality and reciprocity in their relationships. The worker relies on the enabling, exploring, mobilizing, guiding, and facilitating methods described in earlier chapters of this book. As members engage spontaneously with one another, workers must be attuned to the possibility that processes may emerge that will impede mutual aid and require their attention and intervention. The worker’s intervention at this point will involve internal mediation and advocacy skills comparable to the ones described in chapter 10, on helping families deal with maladaptive group processes and relationships. The more quickly the worker intervenes, the easier it will be for members to modify transactions that undermine their work. In contrast, the longer these dynamics continue, the more difficult it will be for the worker to do this.

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Professional Methods and Skills

The first two sets of skills foster the creation of a mutual aid system and encourage members to make connections to one another, but also respect the differences between them. When the social worker uses these skills, this lessens the possibility that maladaptive dynamics will surface (Gitterman, 1989b). Connecting Method

The social worker helps build a mutual support system by using nine skills that connect members to one another. Scanning. The social worker monitors the group by focusing on all the members rather than only on the member who is talking. In social work practice with groups, we have two foci: each individual member of the group and the group as a whole. Therefore, we attend to the behaviors of individual members, as well as the patterns of members’ interactions with one another overall. Directing members’ transactions toward one another. From the very beginning, members are encouraged to talk to each other, not just to the worker. The members’ natural tendency will be to direct their comments to the worker, particularly in the early phase. The worker reminds members explicitly (“Talk to the other members, not me”) and indirectly (the worker scans the group and minimizes making eye contact with the member who is talking), as a means of establishing the norm of talking to one another. Inviting members to build on one another’s contributions. The practitioner encourages members to interact with one another by linking their comments. The worker in the elementary school group might have been more successful had he helped members see beyond their subgroup to the commonalities they all shared rather than using rules to maintain control. This skill depends and builds upon scanning. When workers monitor members’ reactions to one another, they pick up on nonverbal behaviors: “Ben, I noticed you were nodding your head while Alicia was talking. Seems like you might agree?” Encouraging and reinforcing cooperation and mutual support. To minimize the development of maladaptive processes, the social worker supports and guides members to work together supportively and collaboratively: “You all didn’t agree about what to do when your teacher corrects you and you get pissed off, but you expressed your views to each another respectfully. Nobody yelled or threatened anybody. Great work!” (said to a group of teens in an anger management group). Putting into words members’ reactions to one another. Group members express their reactions to one another’s words and actions verbally and

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nonverbally. Using scanning skills, the worker helps members become aware of these reactions—reactions that may convey anything from agreement and approval to confusion, anger, and disapproval. The worker also may need to help members share their reactions in a way that others are able to hear. Encouraging members’ participation. Individual members will vary in their ability to participate actively in discussions, activities, and tasks. In an example from earlier in this chapter, a member of a seniors group, Laverne, was silent during meetings, which became a distraction for other members and prevented her from benefiting from participation. Helping individual members participate (“How about we give Laverne a chance to jump in on the conversation?”), as well as helping others understand that a member can be engaged in more reserved ways, minimize the negative impact that silence has on the group. The worker also might need to reframe a member’s behavior in a way that makes sense to the others (“Everyone has a different way of participating in the group. Laverne seems to prefer to sit back and observe, rather than participate through talking”). Identifying and focusing on common themes in members’ discussions. At times, a group theme is readily evident. Other times, it may be more elusive and expressed behaviorally. For example, some members may cope with the group’s termination by withdrawing, acting out, or questioning the worker’s level of caring. The social worker actively searches, identifies, and focuses on common themes. The common themes are the “glue” that binds members together and reflects their mutual concerns. In the elementary school group, the worker had numerous opportunities to use this skill. For example: “It seems like anytime someone brings up a tough subject—a fight with a parent or a classmate—you guys start fooling around and pick on each other. Maybe it’s hard to talk about these things?” “Everybody is reacting to the group’s ending—John, you’re running in and out of the room. Bill, you have stopped talking to me. Jack, you have put your head down and closed your eyes.” The members all had problems in their social relationships and were reluctant to talk about them. Scanning skills are essential to identifying the underlying themes and bringing them to members’ attention. Connecting the individual to the group and the group to the individual. The commonality that is the foundation of mutual aid may not always be clear, as the elementary school group revealed. The worker consistently looks for ways to reframe individual members’ comments and experiences in a way that resonates with others: “Everyone has their own way of grieving. Pam may not be crying like the rest of you, but that doesn’t mean her grief is any less. Maybe for her, right now, the only way she can handle the murder of her brother is to act strong.” The worker also reframes group themes in a way that resonates with individual members: “Sometimes the only way to handle the overwhelming grief

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you all are experiencing is to laugh or talk about anything other than what you have lost.” “David, I don’t think folks are laughing at you, I think they’re coping the best way they know how—by joking. Because what you just described is incredibly painful.” Using activities and programs to facilitate connections. Many group members are unable to discuss their difficulties, due to their age or emotional, social, or intellectual challenges. In these cases, activities ranging from art and music to movement and games become the means through which members connect to one another and achieve collective goals. In other instances, participation in an activity is the goal of members’ work together. For example, a group for adolescents aging out of foster care focused on cooking skills, grocery shopping, and budgeting prepares members for independence and also provides them the opportunity to connect with others at the same pivotal moment in their lives. Table 11.4 summarizes the skills of building mutual aid in a group using connecting skills. Differentiating Method

Common themes and activities strengthen collective functioning and foster mutual support. The social worker also helps build a mutual support system by fostering members’ autonomy and individuality. The differentiation method requires that the social worker help members balance individual needs with group needs and includes three skills: Inviting members to disagree. Group members—like individuals generally— often have a difficult time expressing differences of opinion or anger at one another. This can lead individual members to “stuff ” (repress) these feelings or to

Table 11.4 Connecting Skills Used to Build Mutual Aid in a Group • Scan and monitor members’ reactions and interactions. • Direct members’ interactions toward one another. • Invite members to build on one another’s contributions. • Encourage and reinforce cooperation and mutual support. • Put into words members’ reactions to one another. • Encourage members’ participation. • Identify and focus on common themes. • Connect individuals to the group and the group to individuals. • Use activities and programs to facilitate connections.

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artificial consensus—or pseudomutuality—among the group as a whole. Alternatively, differences may be expressed loudly and aggressively. In either case, the social worker discourages premature consensus, invites individual members to disagree, and supports differing opinions and perceptions. This skill depends on scanning the group to look for signs of disagreement or anger: “Al, you look upset at what Maryjean just said. Can you let us know what’s going on?” Supporting differing opinions and perceptions. Because members may have difficulty expressing feelings of anger and differing points of view, the worker creates an environment in which honest discussion can take place. The worker reminds members of group guidelines about how differences can be expressed (or establishes such guidelines) and then helps members adhere to them: “Larry, I understand that what Joe just said pissed you off. And he needs to hear your thoughts. But you have to do so in a way that he can hear you. He’s not going to hear you if you’re yelling at him and calling him a motherfucker.” Crediting members’ work. Because members may struggle with accepting and managing their differences, the worker credits their efforts, which encourages continued open and direct communication: “The important thing is that, as pissed as you were with one another, you talked about it. It was hard to do, but you’ve done it really well.” Table 11.5 summarizes differentiating skills. Internal Mediation Method

When groups develop maladaptive group processes, the social worker calls on the internal mediating method and its seven skills, each of which is comparable to those we use when working with families. Developing a transactional definition of the maladaptive processes. The worker first takes a step back and asks, “What is going on here?” This requires the worker to consider both the individual members whose actions and behaviors appear challenging and the way in which the process may be functional for the group as a whole. The worker also asks, “Am I caught up in and unwittingly contributing to the pattern?” The worker understands that the problem lies neither solely in individual members nor in the group as a whole, but rather in the transactions between all members. Scanning and identifying common themes Table 11.5 Differentiating Skills to Promote Autonomy and Individuality • Invite individual members to disagree. • Support differing opinions and perceptions. • Credit members’ work.

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are two skills that assist the worker in developing an understanding of what is going on and the patterns of communication and relationships. Consider the following example: Meghan, a young white social worker, was beginning her group for middle school– age boys referred by their teachers for their acting-out behaviors in the classroom. The school is located in an inner-city, impoverished neighborhood. The student body and most of the staff are individuals of color. In the first session, as Meghan is introducing herself and explaining the role and purpose of the group and her role as the social worker, the boys begin to laugh and joke about her way of talking and dressing, referring to her as “white lady” and sarcastically addressing her as “Ma’am.”

The members’ reactions to Meghan reflect their assumptions about her based upon their obvious cultural differences and social position. Their reactions also can be framed as transference resulting from their and significant others’ infrequent but all too often negative encounters with white people. We return to transference and the interpersonal stress that this can create in chapter 12. Identifying maladaptive patterns for the group. Members often are unaware of transactional obstacles. Identifying maladaptive patterns is the first step to consciousness raising. This can include the role that we play in the maladaptive process. In the example just presented, though caught off guard, Meghan was astute enough to observe, “So, I’m thinking that you guys have some questions about me? We sure are different from one another, aren’t we (smiling)? Maybe you are wondering whether I can help or understand you?” While subtle, Meghan’s comment identifies a dynamic that has the potential to undermine her credibility and members’ ability to accept her offer of assistance. Reidentifying maladaptive patterns for the group. Because maladaptive processes are often repetitive, the social worker reminds the group of prior incidents: “Okay, here we go again, it’s happening right now. Just when you guys started to talk about what’s really bothering you, like cheating boyfriends and friends that let you down, Carmen starts picking on Yolanda, and all of a sudden you’re not talking about how alone you feel anymore.” Holding members to their agreed-upon focus and challenging their avoidance and resistance. Giving up an entrenched pattern is not easy. Member resistance should be anticipated. The worker holds members to the work: “Everybody’s fuming but not talking, what’s going on?” Firmness and persistence convey strength and caring, which in turn can help members face maladaptive processes. Searching for and sustaining the expression of strong feelings. Previously, we described the importance of supporting differences in perceptions and opinions.

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There may be times when the worker missed the need to use this skill. In other cases, after reflecting on the transactional nature of a maladaptive group process, the worker realizes that it may be a reflection of suppressed feelings of anger or frustration. While this skill is similar to supporting differences, it may require more persistence on the worker’s part, since the pattern may have become an entrenched norm for the group: “You all seem really pissed off at each other. What happened? (members are silent) Come on, I know it’s really hard to do this, but if we’re going to do the work we’re here to do, you have to be able to talk about what you are pissed off about.” By inviting the expression of strong feelings, the practitioner conveys faith in the members’ ability to deal with interpersonal stressors and in their capacity for mutual aid. Searching for and identifying common definitions and perceptions. This skill builds upon the two connecting skills of connecting the individual to the group and the group to the individual and identifying common themes. The worker listens carefully for potential commonalities when members have trouble recognizing them. For example, in a group for veterans, as one member began to cry when describing a combat experience in which a buddy was blown apart by an improvised explosive device, others began to joke among themselves, suggesting to the worker that the individual member was in the role of scapegoat. The worker commented, “It’s hard to hear Vic talk about what he saw and see how upset he is, isn’t it? It’s sometimes easier to laugh all the pain away than it is to talk about it.” Renegotiating expectations for participation. The worker may need to engage in an honest discussion with members about how they are working together and assist them in modifying norms or expectations that are creating stress and undermining their ability to work collectively: “I think we need to take a look at how you guys are working together. It’s hard to talk about being bullied in class when everyone’s talking all at once. Let’s work on one person talking at a time, okay?” Table 11.6 summarizes the skills of mediating internal group stressors. Table 11.6 Skills of Internal Mediation in Groups • Develop a transactional definition of the maladaptive process. • Identify maladaptive patterns in the group. • Reidentify maladaptive patterns. • Hold members to their agreed-upon focus and challenge avoidance. • Search for and sustain the expression of strong feelings. • Search for and identify common definitions and perceptions. • Renegotiate expectations for participation.

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PRACTICE ILLUSTRATIONS

A critical aspect of helping with maladaptive group patterns is to understand their transactional nature. The worker avoids the common mistake of thinking, “If only Jerry [the scapegoat or monopolizer] or Nancy and Julie [members of a subgroup] weren’t in this group, things would be fine.” The following practice illustrations reflect the worker’s ability to see beyond specific behaviors to see their underlying meaning and the function they serve in the group. Connecting the Individual to the Group and the Group to the Individual: Helping with Scapegoating

A social work student, Marianna, was assigned to an ongoing, open-ended group in the adolescent unit of a psychiatric hospital. The group met daily, and Marianna led it on the two days she was in the field. The current group consisted of Dewayne, Rafael, and Micah. Each member had been in trouble with the law, with histories of fighting and suicidal thoughts or gestures. In the last few sessions, the boys had worked on issues related to lying, betrayal, trust, loss of hospital friends, and the departure of a favorite psychiatric medical resident. Micah, the newest member, quickly fell into the role of scapegoat. In one session, Micah was complaining about another patient who had been discharged from the unit when the other members directed their anger toward him. Marianna describes what happened: micah: He was just a big bunch of bullshit! He would make stuff up! Man, he said . . . dewayne(interrupts): Well what about you? You do the same thing. Can’t tell you anything. micah: (sighs) I don’t mean to. Dewayne glares at Micah, says something under his breath to him. micah: (softly) I already apologized for that. I told you I was sorry. (He looks close to tears.) Rafael squirms in his seat, glancing sideways from Dewayne and Micah to me. marianna: Rafael, do you know what they are talking about? rafael: (smiles, looks away) Yeah. marianna: Dewayne, what’s up? dewayne: Micah is a liar. He invents stories and no one can believe him. He doesn’t know how to stop it. Who wants to hang around someone like that? He’s immature. micah: Am not. I told you about my dad for real. He ran out on us. He beat my mom and us all the time. He was a drunk and a real shit.

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I remained silent, not intentionally, but because I was confused. rafael and dewayne: (in unison) Liar . . . liar . . . liar . . . liar . . . Rafael and Dewayne begin to whisper to each other. marianna: Yo! (All three look at me.) Let’s get back to the whole group. This isn’t the place for private conversations. Remember last time we talked about stretching the truth, that everyone stretches the truth sometimes for all sorts of reasons. What are some of the reasons why people stretch the truth? dewayne: See, even Marianna thinks you don’t tell the truth. marianna: (after a brief silence) What can we do as a group to help keep each other from stretching the truth? More silence. Micah fights back tears.

This meeting ended soon after with long periods of silence and discomfort, and the scapegoating pattern continued. Three sessions later, Dewayne and Rafael tried to “help” Micah by giving him advice on how to act more mature and stop “lying.” Marianna describes what happened next: marianna: I get the feeling that you guys are pissed off at Micah. Am I right? dewayne: He’s not listening to us. Why bother? rafael: How long have we talked about this and he keeps doing the same thing? Micah sulks, hugging chest protectively. marianna: Micah, you have been pretty quiet so far today. I’m wondering if you’ve heard what Dewayne and Rafael have been saying? micah: Yeah, I have. marianna: (gently) So, how about you let them know what you heard them say? Micah repeats verbatim what was said, looks up and at the other members, while Rafael and Dewayne laugh loudly. dewayne: So why didn’t you just say so, dipshit? Rafael and Dewayne continue laughing. marianna: I’m confused here. You guys say you want to help Micah, and it sounds like Micah heard what you said, and now you’re making fun of him? rafael: We like him. But it’s hard sometimes . . . ’cuz he don’t tell the truth. He just don’t listen. dewayne: He is like a little brother to me. He just needs to learn to be mature. I talk to him a lot and give him advice. marianna: I think that you really do want to help Micah. But part of helping is understanding each other. Sometimes when people exaggerate or stretch the truth, it’s because they’re nervous, trying to impress others. Maybe Micah

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might be feeling like this. It’s tough coming into this place. Not knowing anyone and having to live with each other twenty-four hours a day, seven days a week. That’s really rough. Silence. marianna: Dewayne, you’re looking pretty thoughtful. What’s going on? dewayne: Yeah, this place sucks. I just wanna get out of here. rafael: Me, too. We might as well be in jail. marianna: Micah, you’re nodding your head . . . micah: I hate it here! I wanna go home (starts to cry) . . . Dewayne and Rafael start to giggle. marianna: (softly) You guys just want out, don’t you? I’m thinking sometimes the only way you can handle things is to poke fun at someone else. Silence. dewayne: Micah’s always picking on others, and keeps making crap up. marianna: (to Dewayne) Each of you guys is doing the best you can just to get through the day. Micah has his way, and you have yours. dewayne: (turns to Micah) You haven’t gotten in fights here, but you keep picking on others. You’re funny, but sometimes you don’t know when to shut up. marianna: Does that make sense to you, Micah? micah: Yeah, I know I can be an ass sometimes. I don’t mean to, honest. rafael: I know, man. We all act like idiots sometimes. It’s this place; it sucks.

Marianna’s field instructor had been helping her understand the function that scapegoating served for this group. Early on, Marianna seemed to side with the group and tried to help Micah heed the advice that the others were providing to him. This served only to perpetuate the scapegoating. Dewayne and Rafael could maintain that they no longer had problems—even though they remained on the unit, with no immediate plans for discharge—and to focus on Micah’s shortcomings. “Helping” Micah with his problems provided them with a distraction from their own difficulties. Dewayne had great trouble with intimacy and self-image and used his intelligence as a defense mechanism. Rafael struggled with low self-esteem and used his alliance with Dewayne as a way of bolstering his feelings about himself. Marianna came to appreciate the transactional nature of the scapegoating: scapegoating gave Micah the attention he craved; Dewayne felt empowered and more competent than the others; and Rafael was reassured that he wasn’t the “dummy.” With this understanding, Marianna could identify for members a source of commonality, which was the stress associated with communal living and being confined in a psychiatric facility. She also reframed Micah’s behavior

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in a way that resonated with the others, allowing the group to deepen its work. Subsequent sessions focused on members’ underlying feelings of inadequacy and their fears about what would happen with their criminal cases. Helping Group Members Overcome Their Avoidance: The Importance of Recontracting

Mitchell was placed in partial hospitalization program for adolescents. He led a weekly group that focused on helping the teens understand and manage the symptoms and stigma associated with their mood disorder—typically depression or anxiety—as well as encouraging compliance with their medication regimen. Mitchell expressed frustration that members treated the group “like it was a joke.” He described a typical session: selena: The weekend sucked. My mom and dad were fighting like usual. I tried to step in and that’s when they started beating on me. I ran out of the house and hid at my friend’s. Then my parents called the cops to find me. They showed up at my friend’s house, and it was a frigging circus. mitchell: I appreciate you being able to share this experience with us, Selena. It’s hard to do that. Benji and Marquan are talking and giggling between themselves. mitchell: I want us to talk some more about Selena’s comment in a moment, but there are two conversations going on at the same time and I’m having a difficult time focusing. What does the group think we should do about this? donald: Do about what? mitchell: Do about people talking at the same time someone is sharing their concerns, just like Benji and Marquan were doing while Selena was talking. donald: It really doesn’t bother me. steve: But it bothers me. Selena is obviously having a hard time, and the least we could do is listen. selena: I’m doing okay, but yeah, it’s really not cool. You guys are being so rude. benji: I’m sorry, but this crap is really boring. mitchell: Benji, help us understand—what do you think makes you bored? benji: I don’t know, talking about feelings and stuff. At my other program, I just stopped going to groups at the end. mitchell: What made you stop going to groups? benji: Actually they kicked me out ’cuz I talked so much. mitchell: So the group leader would just ask you to leave when you started interrupting people?

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benji: Pretty much, yeah—that’s what happened. Other members are talking among themselves. mitchell: Benji, I don’t want you to leave the group, I want you learn how to use the group—how to help others and to get help for yourself. Members continue to talk among themselves. mitchell: Hey, guys, there you go again. Benji is talking about something serious here. denise: I don’t think we should ask anybody to leave or anything. I think we should ask them how come they are not paying attention. mitchell: That’s an excellent idea. What do the others think? Steve, Donald, and Marquan nodded their head in agreement. mitchell: So let’s try—what was going on for you, Benji, when you started talking to Marquan before? benji: I really don’t know. mitchell: What do you all think might be the reasons you would be talking, not listening, and not trying to help Selena? loretta: I don’t know about Benji and Marquan, but I know that it is hard for me to talk in groups, especially when we’re talking about stuff like Selena was bringing up. Everyone starts talking at once— mitchell: Guys, again, how about we focus on what Loretta just said. That it can be hard to talk in front of others, even though you’re all dealing with the same thing. Marquan, Donald, and Benji talk among themselves. Loretta turns to Denise, and they start talking. mitchell: Well, okay, I think we’re going to have to stop for now. We’re just about out of time. We’ll pick this up again next week.

Mitchell experienced understandable frustration about this group session. He attempted to interrupt the pattern of members engaging in side conversations, but he was unsuccessful. He seemed to understand that this dynamic reflected the members’ reluctance to discuss the painful issues associated with their mental health diagnoses. He also seemed to understand that the norm that supported side conversations needed to be addressed. However, his intervention relied upon the members’ abilities to identify for themselves their avoidance and to modify the norm on their own. Mitchell decided that he would open the next session by directly addressing members’ avoidance and the norm that supported it: mitchell: So, I’m thinking we need to have a conversation about how you guys are working together. I get the feeling that part of you wants to talk with one

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another about what’s going on—the challenges you face living with the stress and sadness, but the other part isn’t so sure it’s safe. Like Benji, you said you got kicked out before, and that it’s hard to talk about some stuff. And Loretta, you said it was hard for you, too. denise: But talking about our shit is good, that’s why we’re here. mitchell: Yeah, it is. But it isn’t easy. I’m thinking that one of the things that would help is for you all to really try to stick to the guideline that one person talks at a time. You seem to want that, but are having a hard time doing it. I can help with that by reminding you when you start talking among yourselves. Make sense? denise: I’m sick of playing games and all that other shit we do here. We need a group like this—to help each other and not run away from each other. benji: I’m sorry, I’m just not used to talking about personal stuff in a group. mitchell: No need to be sorry. Benji’s not the only one, right? All members nod their heads in agreement. mitchell: Can we talk about what makes it difficult to talk about personal stuff in this group? Members say yes or nod their heads. mitchell: Okay, let’s start by talking about what “stuff ” means and what kind of “stuff ” is difficult to talk about.

The group members experienced difficulty in becoming involved with each other and sharing their life struggles. They avoided interpersonal and personal involvement by simply not listening to each other and engaging in side conversations. Mitchell realized that he had to be much more direct in helping members examine the pattern. He reframes the side conversations as the members’ way of avoiding the risks associated with talking honestly with one another. By doing this, he highlighted an important commonality among the members, and this became a place for them to start: why it was so hard to talk about their “issues” and what those “issues” were. He frames the counterproductive norm of having side conversations in a way that makes sense to members and helps them see that why he will need to help them create a new norm, which is that one person talks at a time. Helping Pregnant Adolescents Face Their Pregnancy: Addressing Group Denial

Often, group members cannot or do not accept a worker’s identification of maladaptive transactional patterns. Giving up entrenched processes is not easy. Avoiding conflict, painful material, intimacy, threatening changes, and escaping into an “illusion of work” may initially be an easier and understandable

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maneuver. For the group to progress, however, the worker has to attend to maladaptive patterns and hold members to their agreed-upon focus. A social worker formed a group for pregnant adolescents who were experiencing stress in their relationships with others, particularly boyfriends and parents. The group’s purpose was for members to support and help one another manage the stress associated with relationships that were disrupted as a result of the pregnancy. However, members struggled to address their common concerns. In the following excerpt, the worker inquired about the “boyfriend situation”: Sabrina begins talking about her boyfriend at great length and describes how he doesn’t want anything to do with her now that she is pregnant. The worker allows her to continue for a while and then says: worker: Have any of you had similar difficulties with your boyfriends? sabrina: (pauses) Antoine [her boyfriend] don’t want to spend any time with me. Silence; members appear bored. worker (turning to Lucinda): Lucinda, did your boyfriend react the same way as Sabrina’s? Lucinda sighs. claudia: My boyfriend, he be real respectful. He started out a real asshole, but I straightened his ass right up. Told him he better be good to his baby’s mama. worker: (turning to Lucinda): What are you thinking? lucinda: Lawrence [her boyfriend], he don’t even call me anymore. I see him out with these other ho’s [whores]. Sabrina, Shawanda, and Claudia start a private conversation. worker (turning to the trio): Let’s give Lucinda a chance, and then you’ll have your chance to share your experiences. It’s only fair to give everybody a chance to talk. claudia (ignoring worker): Oh, but listen to this. James [her boyfriend] say he gonna buy me a gold necklace He takes care of his baby mama. worker: Since you all became pregnant, I know it can be hard talking about how things have changed; talking about some of the difficulties related to being pregnant can really be uncomfortable and hard to talk about. claudia (interrupting): I know, but listen to this. James and me be partying and hanging out. I figure I gotta get my partying in before the baby comes. Shawanda and Lucinda laugh. worker: I really feel bad. You girls have a lot going on, a lot of stress because you’re pregnant. But it seems like you want to just go on like you’re not. claudia: My mother keeps hassling me, telling me I’m ruining my life. Sabrina and Shawanda talk among themselves and laugh.

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worker: I wonder if you have noticed that every time one of you begins to talk about being pregnant and its consequences, you find something else more cheerful to talk about? Silence worker: I think maybe you’d like to believe that nothing’s changed since you became pregnant. But from what I understand things are different. Parents pissed at you, boyfriends and friends disappearing. Lucinda started to cry. shawanda: It’s okay, Lucinda, I cry a lot. My father thinks I am a slut (tears came to her eyes). sabrina: It’s ain’t no big deal, but yeah, I cry too, even though most of my friends be pregnant too. worker: Sabrina, what’s happening for you right now? sabrina (angry): OK, you wanna know, I’ll tell you—my mother kicked me out of the apartment, she wants nothing to do with me. She says I have to find out the hard way what it’s like to have a baby at 15 just like she did. Silence. claudia: (softly) James treat me good, but I know he’s got other girls. That hurts, man. The worker pats Claudia on the knee while scanning the group. worker: You are all going through a lot of changes and pain together. I would like very much for you to help each other with what is going on in your lives.

Members had previously expressed concern over changes in relationships that resulted from their pregnancy. The pain they experienced because of disappointed and angry parents and abandonment by boyfriends led to their collective avoidance of their shared commonality. The worker’s initial attempts to refocus the group were unsuccessful because she addressed individual members’ behaviors, not the underlying theme they reflected. When she pointed out the avoidant behaviors they engaged in, her invitation to share their pain was accepted. “I am not a client”: Helping a defensive member accept help and managing the worker’s anger

Rather than viewing an indigenous leader as an ally who may be letting the worker know what is really going on with the others in a group, the worker may see the individual as a distraction and a threat, assuming, “If only she wasn’t here, this group would be fine.” This may lead to workers feeling that they are in competition with this member for who “runs” the group.

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Timothy, a social work student, was assigned to a group in a psychiatric hospital, the purpose of which was to prepare its members for discharge from the hospital into community housing. After several meetings, a new member joined the group. Mrs. Palmer adopted the role of “helper” and “authority,” based upon her previous hospitalizations and experiences in similar groups, which leads to resentment among some members. Initially, Timothy viewed her as a distraction, and his frustration toward her was evident in the following excerpt from the second session that Mrs. Palmer attended: timothy (to group): It’s so quiet today—why do you think that is? mrs. greenberg: Yes, we have been talking about some of the things that are scary about leaving here. mrs. palmer: I am sure you are afraid. You are always in a daze—you’re not going to be able to go anywhere! Take it from me. You have to have your wits about you to get out of here. mrs. greenberg: I don’t need a spokesman to talk for me. mrs. palmer: Well, I think you do—you need our help. mrs. greenberg (to others): She knows everything, doesn’t she? Members look nervously at one another. timothy (to mrs. palmer): I think you need to let Mrs. Greenberg speak for herself. Silence. ms. phillips: Well, Mrs. Palmer can be helpful to us because she’s been in a group like this before. (to Mrs. Palmer) Where do you think I can live when I leave here? mrs. palmer: Well they all are bad, let me tell you! Members appeared confused and upset. timothy (impatiently): Mrs. Palmer is making you all a little uncomfortable, talking only about all the negatives with your housing options when you leave here. mrs. greenberg: Well, there is a lot of truth in what she is saying. mrs. burgio: Yeah, they better find me an apartment. timothy: How else are you feeling about what Mrs. Palmer said? Members were silent, looking down and avoiding eye contact with the worker. timothy: Well, I guess that’s it for today.

The intern sided with several members, whose resentment toward Mrs. Palmer was evident. He was immobilized by his anger at Mrs. Palmer and consequently withdrew from the group. This left group members feeling abandoned,

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but also divided in their loyalties. Mrs. Palmer’s behavior reflected the fears that members had about leaving, but they also wanted to comply with Timothy’s desire to redirect and silence Mrs. Palmer. Timothy—and the group—needed to examine the meaning of Mrs. Palmer’s comments and actions. However, his anger at her, as well as his fear that he had lost control of the group, prevented him from helping the members to do this. Instead, members sensed that he wanted them to take on Mrs. Palmer for him. Mrs. Palmer dominated the next two meetings, and the power struggle between her and the worker continued. Her anxiety about leaving the hospital trapped not only her, but also the group and the intern. Timothy felt that he had lost the group, and as a result, he became less active and the group floundered, as members felt caught in the middle. Timothy continued to view the problem as residing within Mrs. Palmer and her psychological difficulties and defensiveness. If the group was ever going to help the members prepare for their discharge into the community, Timothy needed to directly address his mistakes, as well as the role that Mrs. Palmer played in allowing the group to avoid an uncomfortable topic. After discussing his reactions and the group’s internal processes in class, Timothy began to see how his anger prevented him from helping the group do its work. In the next meeting, he courageously took on these problematic dynamics and the role he played in them: timothy: I’ve been thinking about our last couple of meetings, and I realize I’ve been going down the wrong path. I’m sure you can tell that I’ve been frustrated and out of patience with Mrs. Palmer. (to Mrs. Palmer) I’m sorry; I wasn’t being fair or really listening to you. mrs. palmer: Well, I’ve just been trying to help everyone. timothy: And I know that. (to the group) I think that as much as all of you might want to leave the hospital, it’s scary to think about life outside of it. Being here makes you feel safe and secure, even with the restrictions. mrs. palmer: In past groups . . . timothy (gently interrupts): Just a sec, okay, Mrs. Palmer? (to the group) I think sometimes it’s easier to talk about everything but your fears about leaving here. Mrs. Palmer has a lot of wisdom to offer, but I think perhaps she has the same fears that others have. And one way to hide those fears is to give advice to everyone else. mrs. palmer: I just know that it isn’t easy out there. I don’t want them (gesturing to others in the group) to be disappointed. timothy (gently interrupts): And that’s great—you are looking out for others, based upon your experiences. But how about if we all talk about what it feels like to

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think about leaving? (to Mrs. Palmer) Can you give others a chance to voice their concerns? mrs. palmer: Well, okay. mrs. greenberg: Well, I don’t like the idea that there aren’t that many places for me to go.

By attempting to get Mrs. Palmer to say that she could be helped in the group, Timothy focused on what turned out to be most threatening to her— leaving the hospital—a fear shared by others in the group. If he had understood earlier what Mrs. Palmer was really saying and understood her need to hide behind her role as an “authority,” he could have more quickly eased her entry into the group and encouraged members to engage in a much-needed conversation about their fears about leaving the safety and security of the hospital. This exchange represented a turning point for this group. By expressing his concerns and feelings instead of acting them out, Timothy lifted a heavy burden from the group. He also framed the underlying dynamic transactionally. All the members were fearful about leaving the safety of the hospital; Mrs. Palmer just expressed her fears in a different way—one that took him a while to appreciate. This honest discussion legitimized members’ fears, and their energies were released for getting to work. Creating a Safe Environment: Helping Members Deal with Group Conflict

A social worker, Francine, developed a group service for five girls, ages 9–11, in a school for youngsters on the autism spectrum. There were 42 students in the school, only 10 of whom were girls. The group was designed to provide members with much-needed support and validation, reduce feelings of isolation, and help members manage their frustration to enhance their ability to learn. At the start, members had difficulty finding common ground, due in part to their ethnic diversity and the intellectual and affective challenges they faced. In the first meeting, Francine explained the purpose of the group and emphasized that the group would be a safe place, where members could express thoughts and feelings without getting hurt or hurting anyone else. Carmen was the newest student, the youngest group member, and the least able to express herself verbally and control her frustration, so she attempted to ally herself with Francine. She constantly sought her attention and assistance. She kept her chair close to Francine or leaned on her when they sat on the floor. Janae was the oldest member of the group and was more self-assured, but very argumentative, with a low tolerance for frustration.

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Carmen was of Puerto Rican descent, and Janae identified as black. Carmen would speak Spanish for teasing and name-calling. Janae was the only group member who did not understand Spanish. In the girls’ first meeting, Francine selected an activity to help members get to know each other. She supplied members with magazines, glue, blunt scissors, and paper and asked that they create a collage that represented who they were, and then share the collage with the others. During this activity, Carmen and Janae began to argue: janae: I already know Angelica and her (pointing at Carmen) from class. (looking at the worker) You know what she does . . . she gives out candy and then takes it back. Carmen pushes her chair back from the circle and puts her hands in her pockets. francine (to Janae): It looked like you are really mad at Carmen right now. Why don’t you tell her about it? Janae repeated her complaint. carmen: I do not! You’re lying! I, I, I . . . (she jumps up and goes over and pushes Janae) Janae and Carmen begin to wrestle, calling each other names, while Angelica, Mandy, and Niki sit silently, looking scared. francine: (pulling Carmen and Janae apart) OK, stop it, sit down! Members started talking loudly among themselves. francine: (standing) Janae and Carmen aren’t getting along right now. One way they and the rest of you can use the group is to learn to get along better. This is a good time for us to talk about how to make this group feel safe to everyone. What do you think? Francine sits down. mandy: No fighting. francine: That’s a good rule—we will not fight in this group. We can get angry at one another, but we can’t hurt one another with our actions or our words. janae: I’m still going to hurt Carmen’s face! Carmen muttered something back in Spanish. francine (interrupting): Remember! We’re not going to allow anyone to hurt anyone else. Carmen slid her chair closer to Francine. francine: (Putting herself between Carmen and Janae) I am not going to let you hurt each other, okay? But I do want you guys to talk to each other when you’re upset so you can work it out. This will make it easier when you’re in class and you get upset. (to Janae) So, how about you try again to tell Carmen what you’re upset about?

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janae: (pointing at Carmen) She lied to me! francine: (to Janae) Try lowering your voice, a little, and tell Carmen directly, okay? janae: (more calmly) You gave me candy and then took it back. The members are silent. francine: Carmen, how about it, can you respond to Janae? carmen: Well, I thought I had more candy, but I didn’t, and Greg [a classmate] said he wanted candy and said he’d hit me if I didn’t give him any. francine: Ah . . . so Carmen was kinda caught in the middle. She was scared of Greg. But Janae didn’t know that, so she thought that Carmen was just being mean. What do you guys think? mandy: I’d be mad if I was Janae. francine: ’Cuz. . . . mandy: ’Cuz Carmen lied. angelica: But she didn’t lie. She was scared of Greg. Greg scares all the kids. He’s mean. francine: Sounds like there was a big mix-up here. Lots of times, that’s how arguments start. People don’t listen to one another. And then they get angry. That’s why we have to try to listen to each other.

Initially, Francine focused on individual members in her quest to create a safe environment, in which members could honestly discuss feelings, including anger at one another. Francine addressed the conflict from Janae’s perspective by encouraging her to tell Carmen how she felt, but she neglected Carmen’s fears of being attacked. When she directed the interaction between Janae and Carmen, she neglected the other group members. The exchange between Carmen and Janae had the potential to convey to members that the group, in fact, was not a safe place, despite Francine’s assurances to the contrary. However, Francine reiterated her commitment to creating a safe place for the girls, which encouraged them to risk engaging in honest discussion. She reinforced safety by physically positioning herself between Janae and Carmen, which also demonstrates her role as a mediator. By helping the girls see how the conflict between two members had relevance for all of them, Francine was setting the stage for them to trust not only her, but also one another and themselves. She needed to continually monitor members’ interactions with and reactions to one another because it was unlikely that they would be able to alter their ways of expressing and dealing with frustration immediately. There continued to be instances when members—particularly Carmen and Janae—lashed out angrily at one another, but over time, they

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became more infrequent as members on their own adhered to the rule that they could not hurt one another. The rule evolved into a group norm, creating the safe environment that Francine had described in the first session of their group. Helping Members Use the Group: Addressing Monopolization

Katie was placed in a public library branch in an inner-city neighborhood as a part of a program called, “Worker in the ’Hood.” The program provided free information and referral services to all library patrons, parent-child bonding and reading time for toddlers, and various support groups for parents, teens, and seniors. Katie led the parent group, which was offered one day a week for 90 minutes and was open to any parent who showed up. The only requirement was that the attendee be a parent. As discussed in chapter 6, this type of open, drop-in group may be necessary in some settings, but it presents distinct challenges to the worker because the membership is unpredictable, and there is no screening to determine a potential member’s appropriateness for the group. There were typically six to eight members who would attend, three of whom were regulars. Because of the drop-in nature of the group, there was no set agenda, although there were a number of recurring themes: community violence, concerns about children’s safety, and the stress of raising children alone and living on limited income. Katie quickly learned that she needed to be sensitive to the emergence of problematic roles as there was no screening. In the excerpt that follows, the group included six members. Shantae, Pearl, and Leilani formed the core of the group and had attended all previous meetings. The other three members were attending for the first time. All the women lived in the nearby neighborhood but did not know one another, and their children ranged in age from infancy and toddlerhood to early adolescence. Katie introduced herself and explained the group’s purpose, which was to provide a place for parents to talk about the challenges they faced raising their children in a dangerous environment (the neighborhood had much gang activity), often on their own. She also went over expectations (“Anything goes— you can talk about whatever is on your minds. We want this to be a place where you can unload some of the stress and worries you live with, like your children’s safety and not having time for yourselves.”). She then invited the core members to explain a bit more about the group: shantae: We can dump all our shit here. Let go of it for a little while. leilani: Yeah, this gives me a chance to do something other than run after my kids, change nasty diapers, and break up fights. You know how it is with them kids.

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Members laugh. leilani: If we don’t laugh, we’ll cry. Members smile and nod in agreement. katie: You guys live with a lot of stress, but before we get into that, let’s take a couple of minutes for you to introduce yourselves to one another. Shantae, Pearl, Leilani, and a new member, Farah, provide brief introductions. Then Tyra, another new member, speaks. tyra: I’m Tyra, I got three kids, and I’m raising ’em on my own. Their daddies are bums—one’s in jail, one’s an addict and, the other’s who knows where. pearl: Been there, honey . . . tyra: (interrupts) I been laid off, so I’m living with my sister and her two kids crammed into one bedroom. katie: It’s tough enough raising kids alone, but then you lose a job, you don’t even have a place to call your own. (turning to the other new member) Can you tell us a bit about yourself? norma: I’m Norma, and like you all, I got these kids that can drive me crazy some times. I love ’em, and all, don’t get me wrong. But it’s hard. tyra: I just take some “me” time. I just tell the kids to go watch TV or play a video game and I have me some “wine and unwind time.” Members laugh, nodding their heads. farah: I don’t drin’ . . . tyra: (interrupting) You don’t gotta drink, you just gotta take time. katie: Everyone needs to try to find time to take care of themselves, but it can be hard because there’s so much going on in your lives. shantae: Ain’t that the truth. If it ain’t one thing, it’s another. I got roaches in my place and the damn landlord won’t do nothing. My youngest needs glasses and I can’t afford ’em. My boyfriend’s fucking another woman. tyra: You gotta dump his ass! Other members nod their heads and voice their agreement. shantae: But I love him, and he gives me money for the kids. I don’t make enough on my own. pearl: I hate having to depend upon Marvin [her boyfriend]. He gives me money but then he goes and gets another girl pregnant. Then he comes back and says he’s sorry. Gives me money and thinks that makes everything okay. katie: So, one thing that you all have in common is men who don’t respect you? tyra: I don’t put up with that shit from no man. (to Pearl and Shantae) You shouldn’t either! katie (to Pearl and Shantae): You might know what you need to do, but it’s hard, isn’t it . . .

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tyra: (interrupts) I’m going to find me a man who loves me and takes care of me. Until then, it’s my babies and me. The members nod their approval. katie: So Tyra wants a guy who respects her, something you probably all want? But . . . leilani: BUT . . . it ain’t never gonna happen. farah: I want a man of faith. They’re hard to find . . . tyra (interrupts): I want me a man with money—lots of MONEY! The members laugh. katie: Money would solve everything? tyra: Money sure would help! The members laugh. katie: But how it is now? A couple of you have mentioned how hard it is. norma: I got these gangbangers on the street dealing drugs. They’re trying to get my oldest boy to run for them. tyra: That ain’t right. Call the cops, or I got some brothers who’d go beat the shit out of them. The members voice their agreement. katie: Tyra always seems to have a solution for things. I wonder if it’s that easy . . . tyra: (interrupting) You just gotta take things into your own hands. Don’t put up with no shit. katie: To try to make things better for yourselves? pearl: No one’s going to do it if we don’t, right? tyra (to Pearl): So you gotta dump that boyfriend. Don’t be putting up with that no good motherfucker.

This session continued in this vein until it ended. In supervision, Katie expressed her frustration with Tyra and her tendency to monopolize the session. Her frustration only grew when she tried to control Tyra, and her resulting attempts to demand work from other members were unsuccessful. What Katie failed to appreciate at the time was that Tyra’s monopolization—and her role at times as the clown and “know-it-all”—and her offering of facile solutions provided others with an easy way out and an escape from the very real stressors that they faced in their lives. A more helpful strategy would have been to point out to the group how Tyra’s actions protected them and allowed them to avoid work. In a different type of group—where the same members would be expected to return for the next session—Katie could revisit this dynamic with them then. But because there was no guarantee of this, Katie learned a valuable lesson about how hard it can be for members to talk about the issues that are most important

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for them and the need for her to view this avoidance transactionally and intervene accordingly. Identifying Commonalities and Underlying Themes: Dealing with Resistance in Response to a Mandate

Todd works in a 90-day inpatient substance abuse treatment program and leads a men’s group focused on helping the members maintain sobriety by identifying triggers and life stressors that contribute to their substance abuse and ways of coping that do not involve using drugs or alcohol. Most of the residents of the program are court-ordered. The group is mandatory for any male resident in the facility. Todd’s group usually has 8–10 attendees; the membership is revolving as men enter and exit the program. The mandatory nature of the group often creates challenges for Todd, as the following excerpt reveals. In this session, there are 8 men, 5 of whom have been attending for more than a month and 3 members who just entered the program. Since the last group session, 4 members had left the facility. Todd explained the purpose of the group and his role as the leader, and had the returning members provide their own view of the group. After member introductions, the following exchange occurred: todd: So, Al, Ray, Lionel, and Donte left the program. And maybe you know that Donte had to leave because he had a dirty urine [i.e., testing revealed drugs in his urine]. That was his third time. And we have the three strikes, you’re out policy. Thoughts about any of that? rico [returning member]: Lucky fucks! Got themselves outta here. The members laugh loudly. morris [returning member]: Can’t wait to get outta this place. Might as well be in jail. bud [new member]: You got that right. It was either jail or here for me. Thought this would be better than jail. But that sure ain’t the case. The members laugh and complain among themselves. todd: You guys are pissed off having to be here. Lots of rules, right? benji (to new members): Wait ’til you see, man. They have rules for everything. Can’t even take a shit without someone looking over your shoulder. The members laugh and nod their heads in agreement. todd: Feels like we treat you like children? rico: Yeah, I’m a man, not some child. They treat us like we don’t have a brain. manny [returning member]: Like we’re criminals.

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antonio [new member]: This is my third rehab. They’re all the same. Do your time, just like jail, and then get out. The members voice their agreement. todd: So you all are just putting in the time here? Then you get out and do your thing again. Silence. Members look at one another. todd: Any of you worried about getting in trouble when you leave? Or being kicked out like Donte? morris: It don’t matter to me. In or out, it’s all the same. todd: “It’s all the same.” (to the group) What does that mean, exactly? antonio: It’s hard to get clean, man. It’s even harder to stay clean. The members voice their agreement. todd: Benji, you seem to agree. Tell us your thoughts. benji: Man, I liked Donte. He was a cool dude. But he goes and uses and gets himself kicked out. todd: And that worries you? Scares you? benji: He was doing well, man. I thought he was going to make it. todd: And if he didn’t make it, maybe you can’t either? Benji nods his head. todd: (to the group) You worry about what happens when you leave? You hate all the rules, but while you’re here, it’s harder to use. But then you leave and you’re on your own. bud: I’ve been in three times, and I stay sober for a while, but then the streets start calling me. denny [new member]: Right. (whispering) “Denny, Denny, Denny, we got your drugs right here, boy.” The members laugh and shake their heads. todd: What I sense is that you guys wonder if it’s worth it to give sobriety a try? You hate the rules, but in a way, the rules are reassuring. They keep you out of trouble.

Readers may question why Todd did not attempt to confront the members’ defensiveness earlier in the session. We contend that his willingness to listen to what the members were saying, both directly and indirectly, allowed him to understand that those complaints and jokes represented their fears about being able to remain sober. Had Todd intervened too quickly, focusing only on the members’ complaints about the program and the requirement that they attend, it is likely that he would have missed this underlying and critically important theme. Todd’s patience and his ability to avoid defending

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the program or judging members ultimately paid off, as members risked talking about their core concerns, most notably their fears that they would never be able to stay clean. “But I’m Not Your Parent!”: When the Worker Is Scapegoated

Yvonne facilitated a group for adolescents aging out of foster care. The group provided both support and education to members as they transitioned into independent living. Yvonne envisioned her role as assisting the group members to acquire the skills and abilities needed to live on their own; the group was “hands-on,” with members learning to cook, budget, grocery shop, write a résumé or college application, and the like. She also sought to help members help one another. In the last group session, members “ganged up” on her, accusing her of not caring. Yvonne responded, “Hey, don’t talk to me that way! I’m just trying to help you!” She had noted some hostility in previous sessions, but she assumed that because she was there to help members learn new skills, the hostility did not mean anything: they were “just being adolescents.” Her field instructor helped Yvonne understand that members’ anger at her may have reflected their anger at their parents and others who abandoned them. It made sense that these feelings would emerge at a time in their lives when they were—in their eyes—being forced out of the stability that foster care had provided them. With this knowledge, Yvonne was able to respond to the members in a more helpful way when the anger surfaced in the next session. A member once again accused her of not caring, and others nodded their agreement. In response, Yvonne commented: I’ve noticed that the last couple of times we’ve met, you guys have seemed angry with me. I’m wondering, though, whether it’s really me you’re angry at? I’m thinking that perhaps it’s your parents and others who didn’t take care of you, who abandoned you? Maybe it’s easier to direct your anger at me than at others—in many cases, you wouldn’t even know how to find your family to tell them how you feel. That’s gotta just add to your anger.

Initially, Yvonne’s comment was met with an uncomfortable silence. The following exchange then occurred: sharon: I’ve been in so many foster homes that I lost track. They didn’t care about me; they just wanted the money. They was no better than my mom. alphonse: Yeah, ain’t nobody want us.

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yvonne: And sometimes maybe you wonder what you did? Why this happened to you? The members nod their heads. yvonne: This could make you really angry at your parents for not taking care of you, at foster parents who didn’t care for you, but also at us for taking you away from your parents in the first place and now sort of “kicking you to the curb.” steve: I got no roots, man. alisha: Me, neither. It’s just me now. But it’s been just me for years. yvonne: And that’s lonely . . . alphonse (interrupting): Can’t trust nobody but yourself! yvonne: That’s gotta be scary. But also can make you pretty sad and angry that you got moved around all the time and then let loose on the world. steve: For sure! It wasn’t my fault my father was a drunk and my mom was crazy! It wasn’t my fault that the foster families you guys sent me to were crazier than my parents! yvonne: You’re right; it wasn’t your fault. None of you were at fault.

Yvonne identifies in a neutral and helpful way the possible source of the members’ anger at her. Rather than respond defensively, she uses their reactions to reach for painful feelings that have surfaced as a result of the significant transition the members face. This leads to a powerful discussion that they needed to have, in which their anger, guilt, bitterness, and fear surfaced. In that moment, Yvonne realized that helping these young adults transition to independence required more than teaching them life skills. They also needed to talk about and learn to manage their pent-up feelings associated with abandonment and deep disappointment in the individuals who were supposed to protect them, including professionals in the child welfare system like Yvonne. Empowering Members to Manage Feelings: Using a Trauma-Informed Lens

The example in this final section of this chapter also comes from Todd’s group. A common challenge that Todd faced was members disclosing traumatic histories in the group sessions. Because not all the members had such histories—or chose not to disclose them—Todd did not want a member to feel isolated from others if he did disclose a history of trauma. He also did not want an individual member, or the group as a whole, to be flooded with feelings that they could not control, since a primary means through which they had coped was through abusing substances. Todd validated and normalized a member’s or members’ concerns and experiences when a trauma history was revealed, identified possible

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resources for those members, and reframed the reactions in a way that connected the trauma survivor or survivors to others. The following excerpt occurred in a session in which the majority of members had been attending for some time. This resulted in a level of comfort that led to more intimate discussions than was typical for this group. Seven men attended this session, six of whom had been in the program for at least two months. The other member, Leon, was new to the program. After introductions, the following conversation took place: todd: So, Leon, you settling into the program okay? Got any questions for any of us? leon: No, I’m cool. todd: Good to hear. It can be a rough adjustment coming into our program with all its rules. The guys complain a lot about the rules, don’t you (smiles)? The members laugh and nod. bud: I’m getting used to the rules around here, man. They keep us honest (smiles). The members laugh. rico: Yeah, they might kick you out if you’re caught using, but at least they don’t kick your ass! The members laugh. denny: You got that right. I’ll take curfews, people watching me pee in a cup than the shit I got when I was growing up. Silence. denny: Did anybody else get the shit kicked out of them? Several members nod their heads, and others look uncomfortable. todd: Looks like Denny hit a sore spot. Rough childhoods? Silence. benji: Those were tough times, man. Silence. denny: You bet your ass. My so-called mother was a crackhead, always bringing in her “boyfriends” to be my new “daddies.” Well, my “daddies” messed around with me. You know, like, sexually. Messed my head up but good. benji: That’s some heavy shit, man. The members agree. benji: Nobody messed with me that way, but they sure beat on me. And my daddy beat the shit out of momma. And when she was drunk, she’d beat on me, too. rico: (to Denny) I know what you mean, man. Silence. rico: I . . . oh shit, man. (starts to cry) I’m sorry, man. I don’t want to be crying like a girl.

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benji: What, dude? Go ahead, man. Just say what you need to say. rico: I got fucked in the ass by my mom’s boyfriends. Didn’t know it at the time, but she took money from them so they could do that to me! Can you fucking believe that?! benji: Whoa, that’s some heavy shit right there, man. leon: (angry) We gotta talk about that shit in here? ’Cuz that’s some pretty messed up stuff. todd: It’s hard to hear this, isn’t it? And you’re right, Leon. It is some pretty fucked up shit. leon: Don’t get me wrong, man (to Rico). I ain’t blaming you or nothing. I just want to stay clean. benji: (angrily) I do, too, man, but Rico’s going through some stuff, here. We gotta support our man, bro. Other members voice their agreement. denny: You’re new here, so you might wanna take a lesson here, bro. We support one another. Members begin to talk all at once. todd: Okay, okay! Hold up (whistles loudly). Let me say something here. Lot of times when people use, they’re running from something, escaping something. Sounds like a couple of you guys had a lot to run from. All but Leon nod in agreement. todd: I’m glad you guys could share what happened. (to Leon) And it is hard to hear this, right? Coming to your first meeting and all this stuff comes up. Leon nods. todd: It takes a lot for people—particularly guys—to admit to such pain. It says a lot about each of you and the group, that you trust one another that much to talk about something that is so painful. (to Denny, Benji, and Rico) You know, while you’re here and when you leave, we can provide you with counseling to help you deal with what happened. After group, how about we talk more about that? The three members nod. todd: Part of what we want to do in the group is to provide the tools you all need to stay sober. It’s a tough call for me right now. I want this to be a place where you can talk about what’s going on. I worry that when we talk a lot about the past pain, it might make it harder to stay sober now. But I also don’t want to cut you off. The members are silent. todd: What’s the silence all about? You guys are never quiet (smiles). benji: I just gotta say thanks to my bros here for listening to me, man. denny: Same here. You guys got my back.

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rico: Got that right. All but Leon voice their agreement. todd: Leon, I noticed that you stayed quiet. Your thoughts? leon: I feel like a complete ass, man. I didn’t mean no disrespect. Members voice reassurance. todd: This was a tough first session. A tough session for everyone. It brings up a lot for everyone, I think. Maybe we can talk a bit more about that . . . how you stay clean when the stress gets so high.

This illustration reveals the challenges that a worker faces when leading a group in which membership changes and the agency structure and function limit the group’s purpose. Todd wanted to facilitate a group with a dual focus on trauma and substance abuse, but the structure of his agency prohibited this more focused purpose. He never knew from session to session what concerns would surface, but he did know that he had to be prepared if a sensitive life experience like sexual abuse should arise. In this session, several potential pitfalls surfaced, but Todd deftly handled them. As he processed this session with his supervisor afterward, Todd questioned if he should have changed the focus when members began talking about past traumas. We agree with his supervisor’s feedback: had he jumped in too quickly and changed the group’s direction, he would have sent a message to all the members that taboo topics were completely off-limits. On the other hand, Todd understood that if he allowed—or encouraged— detailed discussion of members’ traumatic histories, it could undermine their sobriety. He was able to balance the members’ sense of urgency against his obligation to promote healthy coping mechanisms. His use of transparency—admitting his ambivalence about switching gears—was especially effective. Todd also recognized the potential for Leon to fall into the role of scapegoat by being the defensive member. As the newest member of the group, who was unlikely to have the level of trust in and comfort with the other members, it was understandable that Leon would resist talking about or even listening to such painful topics. By validating and reframing Leon’s reluctance, he was able to connect him to, rather than separate him from, the other members. Maladaptive interactions also occur in the worker-client relationship, and just as in groups and families, they have the potential to undermine clients’ ability to work with us and benefit from our assistance. We now turn to these problematic relationship and communication patterns between clients and the worker.

Helping with Maladaptive

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Relationship and Communication Patterns between Social Workers and Clients

Maladaptive patterns similar to those that surface between members in families and groups often arise in the relationship between clients and social workers.

INTERPERSONAL PROCESSES BETWEEN WORKERS AND CLIENTS AS LIFE STRESSORS

Disruptions in encounters between clients and their workers reflect their respective efforts to maximize influence over the situation and the process. Workers may try to influence their encounters with clients through premature and superficial reassurance and interpretation, imposition of values and solutions, impatience with process, avoidance of relevant content and feelings, and inadequate exploration. Often, this reflects workers’ desire to “fix” clients and ease their distress, and at the same time to demonstrate their helpfulness. Clients may try to influence the content and focus of the work when they (1) do not want or are ambivalent about the help in the first place (e.g., mandated clients); (2) are threatened by or uncomfortable with the direction the work is taking; and/or (3) have concerns about the worker’s actions or ability

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to be helpful. Clients’ efforts to influence the focus and direction of the helping process may be reflected in active behaviors like provocation, intellectualization, interruption, and projection; passive behaviors such as withdrawal, artificial compliance, and silence; flight behaviors such as “instant” recovery, canceled appointments, and abrupt termination; and avoidance behaviors such as changing the subject, withholding information, minimizing concerns, and “forgetting” appointments. Sources of Interpersonal Obstacles

A variety of interrelated factors can lead to maladaptive interpersonal patterns between workers and clients. When these maladaptive processes surface, they undermine—if not completely negate—the work. These patterns must be recognized, identified, and directly addressed. Dealing with interpersonal obstacles provides both worker and client with the opportunity to reduce or eliminate the obstacles and deepen their work. Practice Context and Accountability

In chapter 1, we described the ways in which social work practice is defined and shaped by the agency’s mission, purpose, and function, as well as by requirements of federal, state, and local laws and third-party reimbursement. We have discussed—and illustrated through case examples—how these sources of accountability can present challenges to both worker and client as they embark upon and engage in their work together. In chapter 7, we distinguished clients’ degree of choice and the importance of taking this into account when we engage with them. Throughout this text, we have described and illustrated skills that take into consideration the degree of choice and in turn lessen the likelihood that this will disrupt the working relationship. This requires that the worker address clients’ concerns openly, honestly, and early. Disruptions in the working relationship often reflect workers’ reluctance or unwillingness to acknowledge the realities of their practice context or a lack of awareness of their importance. Consider a case presented previously in chapter 7: Kathleen conducted an intake interview with Sofia, a victim of domestic violence, who was seeking shelter at the student’s agency. As required by her agency, Kathleen asked Sofia whether she had ever been abused as a child. When Sofia replied that she had, Kathleen informed the client that she would need to report the abuse to

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local authorities. Sofia was angry and distraught about this. To some extent, this was because Kathleen had not informed her in advance why she was asking this question and what she would be required to do should Sofia answer in the affirmative.

Kathleen later acknowledged in supervision her discomfort with certain realities of her position. Kathleen’s agency required her to ask potential clients about past abuse, and reporting mandates in her state required her to report such disclosures. There is no guarantee that had the worker clarified her mandated responsibilities, Sofia would have reacted differently. We suggest, however, that by avoiding this responsibility, Kathleen increased the likelihood that Sofia would at best, go through the motions of working with her, and at worse, refuse altogether. Agencies expect practitioners to carry out their mission and mandates. If we are not careful, we can “become” the agency rather than “represent” it. The agency’s voice may become so loud that the client’s voice is completely drowned out. The following example is illustrative: Mrs. Peterson’s children were removed from her home two years ago, following the detection of a sexually transmitted disease in her 5-year-old daughter and the discovery of physical abuse of her two sons, ages 14 and 7. Her boyfriend was the suspected perpetrator in each case. For the past two years, Mrs. Peterson denied that her children had been abused and resisted all court referrals for services. She was referred by the court to the family service agency as a condition for the return of her children. When it became clear to her that completing the court-mandated counseling program was the only way to regain custody, she reluctantly came to the agency. After missing her first four appointments, she arrived 30 minutes late, casually entered the worker’s office, and threw herself into a chair. mrs. peterson: Hi. worker: (looking at her watch) I am sorry that we won’t have much time. mrs. peterson: I’m late ’cause my bus was late!Silence. worker: You lost custody of your children, right? mrs. peterson: Yeah. So? worker: Tell me about the situation. mrs. peterson: What’s to tell—they took my children away from me. They said my daughter had some disease or something, like from sex. worker: (after a brief silence) And that upsets you? mrs. peterson: You’re damned right I’m upset! worker: Do you believe your daughter had the sexually transmitted disease?

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mrs. peterson: (in a calmer tone) No, I don’t think she had it, at least I know she didn’t get it from my boyfriend like they’re saying, because I tested negative. Now, if he gave it to her, he’d have it, and so would I. They didn’t need to take my kids away for that! worker: Does your boyfriend still live with you? mrs. peterson: (looking away) I can’t say. Somebody told me not to say anything. worker: Well, if you want our help, then you’re going to have to tell me.

At this point, the session ended due to its shortened length, and the worker and client negotiated their next appointment time. Before she left, the worker asked Mrs. Peterson what she thought about coming to the agency. She responded, “I think you people are really nosy, that’s what I think,” prompting the worker to reply, “Well, we’re nosy because our job is to protect kids.” She wanted to add (but did not) “. . . from people like you.” Mrs. Peterson was angry at the mandate and her loss of autonomy. Her past experiences with social service agencies had been negative and, understandably, she was suspicious, mistrustful, and angry. Rather than respecting and beginning with Mrs. Peterson’s point of view, the social worker personalized the client’s resistance and opened the interview with a hostile question with an implied accusation: “You lost custody of your children, right?” The worker was in the agency’s world, not the client’s. Rather than using the mandate to encourage the client to get the help she needed to get her children back, the worker solidified Mrs. Peterson’s resistance, decreasing the likelihood that any change will take place. Worker Authority, Power, and Professional Socialization

The worker’s authority, power, and professional socialization are potential sources of interpersonal obstacles. As representatives of organizations and the profession of social work, workers are vested with authority. They embody the organization, and clients often test which side workers are on. The worker’s authority may be necessary to motivate clients to obtain the help they need, but do not necessarily want. As discussed in chapters 6 and 7, many clients move through phases of change, beginning in the precontemplation phase, when the only problem that they believe they have is the mandate to obtain help. Ideally, social workers encourage clients to become willing participants in the helping process. Interpersonal stress between workers and clients may arise when workers avoid acknowledging the power they hold and clients’ feelings about this, or they use the power in punitive ways, as the example of Mrs. Peterson illustrated.

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As representatives of a profession, workers have additional authority, apart from what is bestowed upon them by their organization. Professional status lends an aura of expertise and competence. Clients often test the extent to which that status is deserved and merits respect. If the worker personalizes such testing and responds inappropriately, a maladaptive pattern becomes entrenched. Social workers also are socialized to their profession. We take on preferred philosophical and theoretical assumptions about the behaviors and situations of those we serve, both of which provide a frame of reference and bring a sense of order to our work. We must avoid the temptation to rely upon favored theories and assumptions with which we are most familiar, which results in trying to fit a “square peg” (our client) into a “round hole” (our approach to helping them). Professional socialization also can formalize the work and stiffen our approach, undermining our spontaneity and genuineness. The result can be detachment from those we serve. Our assumptions, whether they are accurate or inaccurate, may color our relationships with clients. We may unwittingly select and hear only those client communications that confirm our assumptions, and elements of their communications that do not fit our assumptions may elude us. Social workers committed to advocacy practice may primarily direct people to environmental stressors, ignoring life-transitional and interpersonal stressors. A social worker committed to clinical practice may direct people to life-transitional issues, ignoring environmental and interpersonal stressors. We continually have stressed that working with clients cannot reflect an either/or perspective, since their challenges often reflect both life-transitional, environmental, and interpersonal stressors. In response to the worker’s subtle or obvious efforts to influence and direct, the client has the choice between satisfying or resisting the worker’s presumptions. When clients resist being defined by the practitioner’s assumptions, they are often labeled as “unmotivated,” “nonverbal,” or “resistant.” Rigid belief systems may blind us to the ordinary details and realities of people’s lives and their aspirations, anxieties, and daily hassles. Even when we avoid the pitfalls associated with the understandable desire to bring order and predictability to our work, we must understand that our role as professional social workers privileges us, as discussed in chapter 4. This professional socialization can create barriers in our efforts to engage and work with our clients, as the following example illustrates: Mrs. Taub, 48 years old, sought services from a program providing services to clients who have experienced interpersonal partner violence. She wanted to leave her husband, but she was financially dependent upon him and had few resources of her

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own. Her ambivalence was reflected in her initial reactions to and interactions with the worker. She immediately questioned the social worker’s sincerity and depth of understanding. The new and youthful practitioner, Faythe, was threatened by the client’s testing in their first interview: mrs. taub: I am not really sure how much talking to you is going to help me. I’ve been through this before—about six months’ worth of talking and I really don’t think I got much better. And my husband still hits me. faythe: Well, I certainly do hope that our work together will be more beneficial to you. mrs. taub: I don’t know, maybe I just don’t trust this whole process. I mean, here you have a stranger meeting another stranger, totally artificial. One person doesn’t really give a damn about the other, but she’s supposed to help the other. I mean it really seems absurd and cold to me. Let’s face it—this is just your job. But it’s my life. faythe: I can understand how you’d feel that way, but even in this situation, some real help can happen.

Faythe met with her supervisor, and acknowledged that she felt threatened and was not sure what to say. As a result, she was unable to respond to Mrs. Taub’s core concern: “Do you really care about me as much as I need to be cared for?” Mrs. Taub missed the second appointment without calling. In response to the worker’s telephone call, she attended the next session and introduced a further test of the worker’s trustworthiness: faythe: We missed each other last week. mrs. taub: (looking away) I’m sorry. faythe: What happened? mrs. taub: I felt really ill. faythe: Why didn’t you call to cancel? mrs. taub: I just felt too ill. Are you going to charge me for the visit? faythe: I’m afraid that’s our policy. mrs. taub: I feel that if you cared about me—which I really don’t understand how you can—I mean, you’ve only seen me for a total of two hours. But anyway, if you really cared about me, you’d be more concerned about my health than about the dumb fee. faythe: Mrs. Taub, I am concerned about your health, but we also have a contract that we will meet weekly and that if one of us needs to cancel, we’ll call 24 hours in advance.

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Mrs. Taub continued to indirectly ask the question, “So, do you care about me?” Instead of addressing this directly, the worker fell back upon agency policy, which reinforced Mrs. Taub’s reluctance to engage with her. Once again, the worker “failed” Mrs. Taub’s test. As she continued to process this case with her supervisor, Faythe realized that she had not considered how cultural differences and privilege might have come into play in this case, since she and the client were both Caucasian. She had not recognized that her social position as a professional, as well as her age and higher socioeconomic status, might have undermined Mrs. Taub’s willingness to take a chance with her. In chapter 4, we posited that social workers must consider how their clients see them and the assumptions that they make about them as a result. Mrs. Taub’s fundamental question really was, “How can someone like you understand and help someone like me?” Until this question is answered—and the concerns that it reflects are directly addressed—it is unlikely that Mrs. Taub can avail herself of the help that she needs. Agency Goals Versus Clients’ Needs and Goals

It can be easy for us to forget that our agency’s goals for clients and our clients’ goals for themselves may not be identical. We addressed this discrepancy in chapters 6 and 7, in our discussion of services being mandated, proffered, or sought. Even in cases when clients are receptive to the services they are receiving, what they want from their work with us and what our agency wants for them may be in conflict. This discrepancy often reflects the should versus is distinction. For example, a social work student was placed in a psychiatric hospital’s subacute unit composed of 11 boys between the ages of 11 and 15. A 12-yearold boy, Julio, had had numerous psychiatric hospitalizations throughout his childhood. His parents physically abused and neglected him, and their parental rights were terminated. His mother’s cousin, Mrs. Rodriguez, adopted him at a young age. While Julio had been in the hospital, Mrs. Rodriguez cancelled over half of her family sessions and missed visiting times on the weekends. On a recent home visit, in opposition to the team’s instructions, Mrs. Rodriguez took Julio to visit his biological mother (during prior visits, Julio’s biological mother made numerous promises to him, only to change her mind). Team members were frustrated with Mrs. Rodriguez’s noncompliance and instructed the intern to confront her when they next met. As their interview begins, the intern questions whether the biological mother made any false promises to Julio:

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mrs. rodriguez: No. Like I said, he was with me the whole time and she [the mother] knows she’s not supposed to say anything like that to him. He told me he really wanted to see her, and I talked to him about what has happened with her in the past. Julio says that she’s his mom, but I’m the mom he’s going to live with. He knows that he can count on me because no matter what happens, I will always love him. social work intern: But when things happen that prevent you from coming to sessions or visits, we are the ones who have to deal with the way Julio acts. mrs. rodriguez: It really is hard for me to get here ’cuz of the distance. social work intern: I understand that, but that time you missed the holiday lunch, Julio was looking around at all the other parents and crying, “I want my mommy.” mrs. rodriguez: What was I supposed to do, drive and get into an accident, and then not be here at all for him?! It’s not like I’m just not coming. When I’m not here, I have legitimate reasons! social work intern: When you look at your attendance for scheduled appointments, it doesn’t look that good. Some people may even think that you are not very committed. mrs. rodriguez: I’m very committed to Julio! I have missed work and have taken him into my home. I can’t believe that anyone would say that I’m not committed. It is things like that that makes me think that I want to get him out of the hospital right now! social work intern: I can see that you are very upset by this and getting defensive, but let’s talk about your options and what can happen. mrs. rodriguez: It really makes me mad that you people are saying I’m not committed to him when I’m doing the best I can for him. Maybe you think that I’m being defensive, but I’m really upset by this and by you. I can’t handle this kind of stress with my diabetes (begins to cry). social work intern: I understand that this is very stressful and I am telling you things you don’t like to hear, but nobody is saying that they want to take custody away from you. But a lot of the reasoning behind him coming here was based on your not making visits or attending family sessions. In order for him to be considered for discharge to your home, we need to know that you will be at all the follow-up appointments. mrs. rodriguez: (loudly) That’s not fair! You people need to look at the reasons for my cancelling. When he was home before, I didn’t have problems with him. He was having all his problems in school, not at home. I don’t need family counseling! social work intern: Okay, but part of him being able to function at home means functioning in other settings, like school and in the community.

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mrs. rodriguez: Well, I don’t know what control I can have over him while he is at school. social work intern: If you really want him going home instead of another residential facility, you’ll need to attend family sessions. We can discuss what needs to be different this time around, and make sure that we keep any appointments that we make. You need to know that he may have to go to residential from here, and I want you to keep in mind that he may be placed as far or even farther away.

The social work student was in an untenable position, particularly because her field instructor was part of the team insisting that Mrs. Rodriguez comply with their rules. At some level, the student understood that she needed to explore—without judgment—Mrs. Rodriguez’s point of view and the reasons why she had been noncompliant with the hospital’s requirements. However, as a student, she felt that she had no choice but to defer to the professionals on the team. This resulted in her abandoning her professional mediating function by completely siding with the team, at the expense of exploring Mrs. Rodriguez’s narrative. We understand why a student would feel compelled to comply with the agenda of others in more powerful positions than her (and her client). However, by doing so, she adopted the team’s frustration and annoyance, which in turn interfered with her being curious and concerned about Mrs. Rodriguez’s experiences. A professional social worker faced a similar dilemma. As the following illustration reveals, the pressure to conform to agency dictates, as well as confusing the agency’s goals with the clients’ goals, can significantly compromise the working relationship. A residential treatment center required children awaiting adoption to create a “life book” as emotional preparation for this critical transition. Writing and illustrating their life stories was expected to help children develop a sense of continuity and positive self-concept. The social worker was assigned to help 14-year-old Malcolm, who was being adopted by a member of the childcare staff. His biological parents relinquished their parental rights a few years ago. The social worker was to help Malcolm work on his abandonment issues and behavioral outbursts. Malcolm did not want to meet with yet another social worker, but the service was mandated. While seeking agreement on focus and plans, the worker was unable to arouse his interest or energy. The life book did engage Malcolm’s interest. However, the client was unaware of the agency’s and worker’s hidden intent to use the book to encourage him to discuss his feelings of abandonment and loss. He expected the book to be a photograph album of his

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loved ones and his accomplishments. He did not want “bad stuff ” in his book, so he excluded his biological family. During their first meeting, the worker mentioned his “other family,” meaning his biological parents. Malcolm stopped her in midsentence, saying, “I’m not talking about that with you!” He refused to discuss this subject, as he had in the past. After several more sessions in which Malcolm excluded his biological parents from his life book, the social worker brought in a picture of his biological parents to include in the book. Malcolm jumped up, started going through her desk drawers, ripped up some papers, and ran out of the room. After the “life book” activity failed, the worker suggested a trip to his old neighborhood. Malcolm turned his back on her. When she persisted, Malcolm shouted, “NO! I don’t want to talk about them, I don’t want to go there!” and stormed out of the office. That night, he ran away.

The worker had felt pressure from the agency’s demand to carry out its policy of encouraging children to address their feelings about their biological families via the life book. Malcolm’s pain was drowned out by the agency’s “voice” and assumption that it knew what was best. By taking the agency’s side over her client’s, the worker alienated Malcolm and added to his distrust of social workers. She failed to appreciate that her obligation lay in mediating between the agency’s demands and the wishes of her client. We discussed the skills associated with this role in chapter 9. As professional social workers, we face the challenge of deferring to the “wisdom” and wishes of colleagues and the agency itself, or standing up for the interests of our clients. While the ethical decision is clear, the challenges we face in upholding our obligations to clients can result in our taking the course of least resistance. Differences between Client and Worker Expectations

Clients often need help with immediate and current life issues, but a worker might concentrate on past experiences to uncover underlying problems. A client may seek advice and direction, while a worker may seek psychodynamic explanations and insights. A client with a history of childhood trauma seeks assistance for a problem with substance abuse, but the worker wants to focus on the “real” problem—the underlying trauma history. As discussed in chapter 4, differences in social position, status, and identity and background may also affect the worker-client relationship by giving rise to incongruent perceptions and expectations. When clients’ lifestyles, adaptive patterns, values, and perspectives are not respected, testing and resistance become methods of coping (Gitterman, (1983, 1989a). Note the following scenario:

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Mrs. Cooper, a 32-year-old African American woman, placed her 11-year-old son, James, in a residential treatment center as a result of truancy and his aggressive and assaultive behavior at school and at home. She was assigned to meet with a young, white social worker. In their first session, Mrs. Cooper’s sense of urgency focused on her intense anger toward her husband: he had broken up the family, physically abused her, and neglected their children. Mrs. Cooper described her husband’s drug use and involvement in the drug trade and the loss of their housing due to his need for money to finance his drug habit. Mrs. Cooper left her husband, but she revealed that she had to leave her son with her husband because she had no means to support him. She took her son back when his father was found to have significantly neglected him. The worker believed that the fact that she left her son with his father indicated that Mrs. Cooper was not a good mother, and that their focus should be on teaching her how to be a better parent. When Mrs. Cooper told the worker she blamed her husband for James telling lies and for being a poor role model for her son, the worker suggested that they should focus on her “anger issues.” The worker continued to focus on her son, his problems, and Mrs. Cooper’s parenting. After the first session, Mrs. Cooper canceled the next four appointments. With each cancellation, the worker’s negative feelings toward Mrs. Cooper’s perceived lack of concern for her son intensified and her view that she was a poor parent solidified. She posed the question to her field instructor, “If she didn’t care enough to come to sessions, then how much could she care about her son?” The following excerpt is taken from the second interview, which occurred three months after the first. The worker continued with her agenda of “teaching” Mrs. Cooper: worker: What would James say about his father? mrs. cooper: James would say that he loved his father. worker: Right, so don’t you think it makes sense that he would want to see his father? mrs. cooper: Yeah, I guess so, but his father’s a bad man and he has a bad influence on James. worker: But as his mother, it’s important to put yourself in James’s shoes to see how he feels. mrs. cooper: I know I have to understand James, but my shoes have a whole lot of stuff that come with them. worker: But you want to be a good parent for your son, right? mrs. cooper: But I went through so much bullshit with Jimmy’s father. worker: I understand how angry you are at Jimmy’s father, but I think it’s important that we try to keep your anger toward his father separated from Jimmy.

At several points in these two sessions, Mrs. Cooper offered her concerns to the worker. The worker, however, was so set on what she believed the problem

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was that she failed to hear what Mrs. Cooper was telling her about what she herself wanted and believed that she needed. Given the worker’s unwillingness to move out of the world of should, it is unlikely that Mrs. Cooper will benefit from their work together. Mrs. Cooper may or may not express her dissatisfaction with the worker directly. In fact, it is likely that she will not explicitly tell the worker that she is not being helpful. However, Mrs. Cooper’s actions— missed appointments and behaviors that the worker will likely see as indications of resistance or noncompliance—will inevitably reveal her frustration and sense of helplessness as she tries in vain to get the worker to listen to her. Interpersonal Control

Struggles for interpersonal control in the worker-client relationship often reflect one or more of the sources of maladaptive communication and relationship patterns just identified. Workers and clients both have resources to gain control over the helping process. Workers possess needed information, concrete resources, and procedures for referrals. They also have influence on the relationship due to personal qualities like friendliness, warmth, and being articulate. Clients may become dependent upon their worker’s approval and sensitive to subtle disapproval or judgmental statements. Clients also have means to wield interpersonal influence on the working relationship. They may desire to control the focus and content of the interview or the relationship through active (refusing to discuss a topic), passive (remaining silent), flight (missing sessions), or avoidance (changing topics) behaviors. Problems arise when the worker or clients use their efforts to exert control in a way that blocks reciprocity and open and honest discussion in their relationship, as the following example reveals: Mrs. Charles, age 23, married with two young children, had been hospitalized three times within the last two months, and treatment complications resulted in a total hysterectomy. The client’s surgery and hospitalization led to financial problems due to the high medical bills and her loss of income while she was hospitalized and recuperating. During her recuperation in the hospital, she also tearfully commented to a nurse, “I have nothing left inside me.” Mrs. Charles asked a nurse to notify the social work department that she wanted to see a social worker. Prior to visiting the patient, Gwen, the intern, was warned by the nursing staff that Mrs. Charles was highly agitated and “nasty.” When Gwen entered Mrs. Charles’s room, she described the patient’s demeanor as “cold” and “hostile.” The student’s process recording reveals their exchange:

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mrs. charles (angrily): I’m glad you’re finally here. I called your office just a few minutes ago to be sure someone was coming up. gwen: Yes, Mrs. Charles, your nurse phoned the office, but we were in a meeting, so I didn’t get the message until just now. Is there something I can help you with? (I immediately felt on the defensive and found myself somewhat annoyed.) mrs. charles (angrily): I wouldn’t have called you if there weren’t something I needed! I can’t pay my hospital bill. I have two small children at home. My husband is between jobs and working at night. He hardly makes enough money to support us, and the bills are out of sight. I’ve applied to Medicaid and I don’t know where I stand. Those people over there are so stupid; they don’t know what’s going on. gwen: How can I help you with Medicaid? (I was getting angry at her anger at me, so my response was pretty curt.) mrs. charles: You’re a social worker, don’t you deal with them? gwen: Well, the accounts department handles billing problems, so they are the ones to contact Medicaid to get your number. But if you’d like me to give them a call to check on the status of your case, I can do that. I’ll get back to you when I can, probably in an hour or so. mrs. charles: (slumped in her bed) Well, do what you can.

Throughout this brief session, Gwen admitted later to being overwhelmed by Mrs. Charles’s intense feelings. As result, she was unable to see beyond her patient’s tone of voice, glaring look, and combative style. She became caught up in an emotional power struggle, fueling the confrontation rather than reaching beneath her client’s anger and connecting to her despair. Gwen helped Mrs. Charles apply for public assistance, food stamps, and Medicaid for catastrophic coverage, but Mrs. Charles was still responsible for $6,000 of her medical expenses. This news intensified the patient’s feelings of desperation, loss, and fear, which led to her combative style, which staff interpreted as her being unappreciative. While this helped her feel more in control of what she experienced as an out-of-control situation, it decreased the desire and ability of the intern, as well as other hospital staff, to be helpful. Gwen had another opportunity to meet with Mrs. Charles when the client returned for a subsequent hospitalization. The intern saw Mrs. Charles’s name on the admission’s chart, and reluctantly went to see her. The exchange went as follows: mrs. charles (in a panicky voice): We appealed the decision that we pay the $6,000, but we just got the letter from Medicaid turning us down. Where are we going to get the money?!

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gwen: All right, well, okay. Please calm down. Let me get some information from you. When did you get the letter? mrs. charles (panicked): I don’t know! Like yesterday! I just said we just got the letter. What difference does it make when we got it? What matters is we have to come up with the 6,000 bucks, and we don’t have it! gwen (sternly): I’m just trying to get the facts here, Mrs. Charles.

Throughout this session, Mrs. Charles wanted to vent, and Gwen wanted to gather facts. They had discrepant agendas: Mrs. Charles wanted a sympathetic and patient ear, while the intern wanted to collect the facts and resolve the problem. The more Gwen failed to listen to what her client was saying, the harder Mrs. Charles tried to be heard. As a result, Mrs. Charles became even more agitated and unpleasant. Gwen became even more overwhelmed by her patient’s challenges, and she felt threatened and intimidated by Mrs. Charles’s words, actions, and demeanor. The worker and client were caught up in a vicious circle of vying for control, with Mrs. Charles saying, “Listen to me,” and the worker saying, “No, you listen to me.” The result was that neither listened to the other. Transference and Countertransference

Above and beyond the specific focus of our work, our reactions to our clients— and theirs to us—are always present as we engage with one another. As many examples in this and previous chapters have revealed, at times our clients will frustrate and confuse us, and may anger us, and this may lead us to feel despair for their well-being as well as for ourselves. In turn, we will frustrate and sometimes anger our clients as we demand them to work on their problems, encouraging them to address issues that may be stressful, painful, or embarrassing. We are entitled to our feelings and reactions, whatever these may be, as are our clients. Our responsibilities as professional social workers are to ensure that our feelings and reactions do not undermine our work with clients and help them acknowledge, understand, and manage their own responses to us. These dual responsibilities require a high level of self-awareness, self-monitoring, and willingness to be honest with ourselves, our clients, and our supervisors. There are times when our reactions and those of our clients are not as easily identifiable or understandable. Transference refers to client reactions and responses that reflect unresolved issues in their relationships and experiences with others. Clients often are unaware of these reactions when they occur, or where they come from. Because social workers are likely to be caught off guard and be confused by these reactions, they may experience

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them as unfair and unwarranted, which may lead to defensiveness. Countertransference refers to comparable reactions that workers have to clients. Like their clients, workers often fail to recognize their reactions when they occur or understand their source. Traditional conceptualizations assume that transference and countertransference stem from workers’ and clients’ difficulties with significant others like parents and caregivers that surface in the working relationship. Conventional wisdom holds that these reactions are self-reinforcing and usually cooccurring. Transference leads to countertransference, which in turn reinforces transference. The following extended example is illustrative of the self-reinforcing nature of transference and countertransference. Greta, age 50, sought help from an outpatient mental health clinic because of feeling “extremely sad, hopeless, and powerless” about her marriage. Greta described her inability to assert her needs and wants to Steven, her 58-year-old husband, and to her 27-year-old daughter. Greta repeatedly described her helplessness, despair, and anger, as well as her views of others as bullies and abusers and herself as a powerless victim. The social work intern, Michael, became increasingly frustrated but also overwhelmed by Greta’s distress. He felt that he should be able to find immediate solutions for her issues. His experience mirrored Greta’s; both of them felt vulnerable and out of control. Without fully understanding his reactions, he acted out his feelings via confrontation, impatience, and anger. Exchanges from the 11th interview illustrate the problematic and self-reinforcing interpersonal pattern occurring here: greta: Steven went to Pennsylvania [to visit his parents] with me. He was in an awful mood. He behaved even worse at his parents, abusing and making fun of me in front of them. When he does this in front of his parents, I wanted to defend myself. But I couldn’t in front of his parents. One day I wanted to go to the movies, and Steven started screaming, “What! You say you are going to the movies and screw me, right?” He grabbed the car keys, so there was nothing I could do. michael: Why didn’t you say anything? greta: ’Cuz I can’t! It’s always the same. I feel powerless, but it’s so stupid. I end up in the same situation saying, “I don’t deserve this.” There is always a bizarre predictability to Steven’s behavior. So why should I get upset any longer? michael: You need to learn to assert yourself. greta: I just told you, I can’t! I say I want to go to the movies, and he takes the car keys away, which I can only retrieve by physical force, causing a major fight. There’s nothing I can do!

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michael: Well I still don’t understand why you couldn’t have just asked him for the car keys. Why didn’t you? greta: Because he wouldn’t give them to me! Hell, you’re a man, you just can’t understand. michael: But you gave in to him as soon as he started yelling. greta: I’d be stupid to demand something that would start a physical fight, I can’t do that. michael: But he shouldn’t be allowed to act like a child. greta: But he is. You just don’t get it. What should I do? I better not get so upset that I say, “Give me the keys, or else,” because it would be “or else.” michael (in exasperation): What is it that keeps you in this marriage!?

Greta was seeking the student social worker’s affirmation and understanding of her difficult, stressful, and painful situation. What she needed was his help in sorting out priorities so that the issues became less overwhelming and more manageable for her. Instead, Michael approached her with disbelief, judgment, and accusation. As he processed this intervention and the interpersonal tension with his field supervisor, he began to appreciate the two interdependent dynamics that were at play. Greta’s struggles with and resentment toward her husband began to surface in her transactions with Michael (transference). Michael unknowingly obliged her and was annoyed by her passivity and helplessness. He ultimately realized that his anger was triggered by his own past and the pain that he experienced due to the prolonged, conflictual divorce of his parents (countertransference). His mother occupied a similar role as Greta’s; when he asked Greta why she stayed in her marriage, it might have been a question that he actually had for his mother. In his process recording, he wrote, “I finally realized my impatience and frustration with Greta was in part coming from my anger at my mother, who was unable to protect herself and her children from an abusive father and husband.” Michael and Greta were locked in an ongoing battle. Initially, Greta’s resentment toward him reflected her anger at her husband. However, when he responded with resentment of his own, Greta’s anger at his inability to understand and help her escalated, which in turn intensified his anger at her. Michael took the first step toward resolving this interpersonal conflict, which was understanding its source. However, its resolution required him to discuss openly and honestly with Greta their reactions to one another and the reasons for them. We will return to the skills required to do this later in this chapter. More recently, a number of authors have argued that transference and countertransference are natural outcomes of a relationship in which worker and

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client engage with one another authentically (Fuertes, Gelso, Owen, & Cheng, 2013; Shaeffer, 2014). Clients’ comfort with and trust in workers creates a safe environment in which they react to the workers—usually without realizing it— in a way that reflects problems that they have had in other social relationships. Countertransference may not necessarily reflect workers’ unresolved issues, but rather may be indicative of the ways in which clients affect them. Note the following example: George was seen at a family service agency for the sexual abuse he experienced as a child. The perpetrator was his brother. When he told his mother about what his brother was doing, she refused to believe him. George and his worker, a young woman, began discussing the anger he felt toward his mother, and the worker pointed out how that anger had been generalized to all women. George became very angry and loudly said he “hated” women and did not trust them. In response, the worker told her client that the session was over because he “threatened” her, and this violated agency policy. The worker immediately sought out the clinical director, and, with George present, described George’s angry outburst. The director informed George that he was terminated from the agency, effective immediately. George was then escorted off the property and told if he returned, the agency would seek an order of protection from the court. This led George to have great difficulty connecting with a subsequent social worker. (And it should be added that his subsequent difficulties with another worker reflected transference: his anger and sense of betrayal at the first worker was projected onto the next worker he saw.)

One of the coauthors was acquainted with both George and the worker. To the coauthor’s knowledge, there was no reason to believe that the worker’s reactions reflected unresolved issues in her personal life. However, the worker was about the same age as George and relatively inexperienced. It appeared that George’s anger frightened her. Even though his behavior was not directed at her, she experienced his loud tone of voice, forceful gestures, and angry facial expressions as threatening. Transference and countertransference have the potential to disrupt the working relationship and undermine the worker and clients’ efforts to achieve clients’ goals. However, they also have the potential to deepen workers’ and clients’ understanding of one another and themselves, as well as their work together. To minimize the potential for disruption and maximize the potential for growth, the worker must recognize manifestations of transference and countertransference and directly address these with the client.

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Taboo Concerns

Workers’ and clients’ difficulties with taboo topics like sex, sexuality, and death, dying, and grief may be significant sources of interpersonal stress when one or both parties seek to avoid dealing with these stressors. Many social workers, particularly those who are new to the profession, find it difficult to invite clients to tell their story and to explore and clarify particular details when the stressors are sensitive in nature. The tendency to avoid direct discussion of intimate or painful material often reflects cultural taboos. For example, female clients whose cultural heritage places emphasis on male dominance may have difficulty acknowledging being victims of domestic violence, while a heterosexual social worker may experience discomfort discussing sex with a gay couple having difficulties in their sexual relationship. The pain and possible embarrassment inherent in this content may overwhelm social workers, generating anxiety and discomfort. Social workers also may avoid broaching taboo topics out of a desire to “protect” clients, or out of fear that this might anger them. The following example illustrates the power that avoidance of and discomfort with a taboo concern has to create stress in the worker-client relationship. Shana was placed on the oncology unit of a local hospital. She provided supportive counseling to patients during their stay, assisted with their discharge from the hospital, and gave follow-up counseling as needed. She was assigned to meet with Mr. Daniels, a 55-year-old man who had surgery to remove his prostate due to the aggressive nature of his prostate cancer. During his hospitalization, Shana discussed with Mr. Daniels possible complications associated with the surgery, one of which was sexual dysfunction. Mr. Daniels expressed concern about this, but Shana and he decided it was best to “hope for the best” instead of worrying prematurely about something that had not yet happened. Shana continued to follow Mr. Daniels after his discharge with weekly phone calls, and after three months, he asked if he could meet with her, since he was having “some problems down there.” He and Shana agreed to meet after his visit with his surgeon. The following exchange occurred: shana: So, you said you were having some problems? I assume you discussed this with the surgeon? mr. daniels: Yeah, I did, but he wasn’t really all that helpful. He said that it was a common side effect of the surgery. Just something I gotta live with. shana: And what was that?Silence. Mr. Daniels fidgets in his seat. shana: Can you tell me what it is?

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mr. daniels: Well, you know, it’s what we discussed. About sexual stuff. shana: Oh, so you are having some problems in that area? mr. daniels: Dr. Elliott [the surgeon] told me just what you said. It’s just something I have to live with. shana: That must be hard. You knew it was a possibility, but hoped that it wouldn’t happen to you. mr. daniels (angrily): Well, you and I talked about that it would be better not to worry about something that hadn’t happened yet. But then it did happen. shana: But you did know it was a risk. . . . mr. daniels: Yeah, but I just didn’t want to think it could happen to me. shana: And now it has, and that’s hard. . . . mr. daniels: You can’t possibly know how hard! I think I should have just lived with the cancer! shana: Well, like I said, we always tell our patients that it’s possible they might have sexual problems afterward. You knew that going in. mr. daniels: Well, yeah, but still . . . it doesn’t really sink in until it happens to you. shana: So, now you have to face the reality? mr. daniels: Yup. And that reality sucks! shana: But look on the bright side. You’re cancer-free, and the doc says that they got it all. mr. daniels: (Still sounding angry) Sorry if I’m not seeing the bright side right now!

Both worker and client had difficulty talking openly about a topic that was of great importance to him—his inability to function sexually. Readers will note that it is never clear to the worker what precisely is wrong; sexual dysfunction following prostate surgery can range from complete inability to get an erection, to loss of libido, to an inability to have an orgasm. Because Shana never asks, she has no way of knowing exactly what sexual problems Mr. Daniels has, which leaves her unable to be helpful. Mr. Daniels does not volunteer this information. This may stem from his own reluctance to discuss his sexual functioning, particularly with a young woman, as well as from his perception that Shana was not comfortable with this topic. It also appears that Mr. Daniels is understandably angry at his loss of sexual functioning (whatever that means), and his anger was being directed at the worker. Unfortunately, Shana’s desire to avoid talking about Mr. Daniels’s sexual problems and to focus instead on propping him up with empty reassurance (“But you are cancer-free”) and reminding him that he knew about the possibility of sexual problems prior to the surgery serves only to deepen his anger at her and her need to avoid both his anger at her and his sexual dysfunction.

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Client Defenses

When faced with painful or difficult issues, clients often resort to denial or negation as a way of coping. While these responses can be adaptive, they also can become obstacles to dealing with the stressors and the associated distress. Practitioners often have difficulty identifying and responding to denial and avoidance. As a result, workers may join with the denial or back off out of fear of “offending” their clients. Alternatively, they may seek to break down clients’ defenses through persistence and “badgering” them. Neither response will diminish clients’ defensiveness, and both are likely to lead to interpersonal stress and widening the gap between worker and client. Clients are much more likely to put aside their defenses when they believe that the worker’s efforts are motivated by genuine concern and warmth. For example, Mr. Wallace, a 60-year-old married man, was recently admitted to the hospital, diagnosed with a serious, usually fatal form of leukemia. Mr. Wallace’s oncologist requested that a social worker be assigned to help him process his diagnosis and prognosis, as well as to offer support to his wife and two adult children. In offering services to Mr. Wallace, the social work intern, Kayla, assumed that he would be accepting of her efforts to help him with the diagnosis. After three sessions, though, Mr. Wallace still would not discuss his diagnosis or prognosis, which led the intern to try to pressure him to talk about it. When he continued to avoid the conversation, she became annoyed. Prior to their fifth session, Mr. Wallace’s physician informed him that his treatments were not working but would be continued in the hope that his blood cell count would improve. He was informed that he would become more physically ill as his body battled the disease. The intern assumed that this latest setback would motivate Mr. Wallace to “open up and connect to his feelings about the recent information he had received.” She met with Mr. Wallace a few minutes after the physician left his room. Although Mr. Wallace did not discuss his diagnosis with Kayla in their sessions, they had bonded over discussions of engineering: mr. wallace: You really need to tell your brother that mechanical engineers had it easy in college. The real engineers are the electrical engineers like me, and the nuclear engineers. (smiles). kayla: Well, I will mention it and see what he says, although I think he would disagree! I can imagine that being here for so long, and receiving all the treatments you have received, must be very difficult for you.

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mr. wallace: Oh, I’m fine. I am going to beat this. I’m doing great with these treatments. This is just a temporary issue, and then I’ll be back at work. I haven’t been sick. I’ve been up and around, making sure I get my exercise. You know, you might want to tell your brother that he should consider getting an MBA. I have one. I’ve owned my own business for several years and I own five houses. I’ve been really successful once I got my MBA. kayla: I certainly notice that you have good color, and that’s really awesome that you feel well. But don’t you worry at all that your treatment isn’t really working? mr. wallace: Nahh. I’ll be back in no time. This is just a temporary setback. Did I ever tell you that I also studied medicine? I went to med school and took some classes to learn about Chinese medicine. That’s why I’m into special diets and all that. kayla (interrupting): I think you did mention that you did some studying of different medicines in the past. But getting back to your health right now—you are really sick. How is that impacting you? mr. wallace: Like I said, I’m fine. The doctor was just here, and we talked about how I’m feeling. I’ve still been able to get up and move around on my own. kayla: I’ve actually seen you heading down to the library. I admire your strength on being able to still get around. What is the doctor’s assessment of how well you are doing? mr. wallace: Oh, you know doctors. They have a whole lot to say and sometimes never say anything. He talked about my blood cell count and all of that medical terminology. kayla: Can you remember any of what he said? I may be able to decipher some of it for you. mr. wallace: Well, he talked about my blood cell count and the treatments I have been getting. kayla: How is your blood cell count? mr. wallace: Well, it’s pretty much the same since I was admitted. But you know this is just the first round of treatment. So we do it again and then retest. The good thing is I haven’t been sick yet, just a little night sweats. kayla: Aren’t you worried at all about what the doctor shared? mr. wallace: Hey, one thing you need to learn is that engineers never worry (laughs). We’re very factual people and like to have proof. The doctor showed me the results. I have proof that he is right. I’m pretty confident the treatments will begin to work because I’m not supposed to be feeling so well. kayla: I am glad that you are feeling so well. You really do have good color. Is there anything that you feel you need some help with?

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mr. wallace: Nahh. I’m all right. Actually I am pretty tired right now and should probably rest, so thanks for stopping by and I’ll see you again later.He points to the door. kayla: Oh, okay. Well thanks for letting me take so much of your time. It was great to talk to you. I’ll see you in a few days. Bye.

Mr. Wallace used his professional status and successes as a means of defending against the reality of his situation, wanting his worker to see that there was much more to him than being a cancer patient, in a hospital gown with an IV in his arm. In supervision, Kayla admitted to feeling intimidated by his successes and accomplishments, and this was exacerbated by the significant age difference between them (she was 21). As a result, Kayla felt inadequate and overwhelmed. In her process recording of this session, she insightfully wrote, “When I am with him, I feel very self-conscious and inept . . . He maintains a wall of defense, which results in my wall of defense going up, and we face each other stone faced and stone walled.” The intern assumed that Mr. Wallace would share his vulnerability, pain, and despair over his potential dying and death. Instead, he desperately struggled to maintain control in the only way he knew how, which was to avoid even considering—much less talking about—the possibility that he would not survive his cancer, focusing instead on his many accomplishments. Mr. Wallace was afraid of revealing his vulnerability, viewing this as a sign of weakness. Kayla also struggled with her own feelings of vulnerability, generated by her client’s façade of invincibility and her inability to “get through” to him. Their fears were intermingled and self-reinforcing. In order to help Mr. Wallace, Kayla would have to find the courage to openly and honestly share her concerns and feelings and encourage Mr. Wallace to do the same. Table 12.1 summarizes the sources of interpersonal obstacles that workers and clients must overcome.

Table 12.1 Sources of Interpersonal Obstacles in Worker-Client Relationships • Agency authority and sanctions • Practitioner authority and power • Professional socialization • Differences between client and worker expectations • Attempts to exert control by both worker and client • Transference and countertransference • Taboo concerns • Client defenses

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Trauma-Informed Considerations

Interpersonal stressors between worker and client have particular relevance when working with survivors of trauma. Traumas often stem from taboo concerns like sexual abuse and involve extremely painful reactions like grief and rage. Clients with histories of childhood victimization may be particularly prone to engaging in transference, projecting their feelings and reactions onto their workers. Authors have stated that working with trauma survivors will lead to strong affective reactions in their workers. These reactions—which we refer to as indirect trauma—are viewed as occupational hazards; the question is not whether workers will be affected, but rather how and in what way their work will affect them. Three manifestations of indirect trauma have been identified (Knight, 2010; Levenson, 2017). Two of them, secondary traumatic stress and vicarious trauma, parallel reactions that survivors themselves experience (Knight, 2015; 2019). Trauma survivors often experience stress reactions that include flashbacks, panic attacks, and nightmares. Research reveals that workers also are likely to experience secondary stress reactions in response to their work, including hypervigilance and intrusive thoughts (Bride & Jones, 2006; Knight, 2010). Trauma survivors often develop a worldview characterized by fear and powerlessness and view relationships with others with mistrust. Distortions in workers’ worldview also are common (Dombo & Blome, 2016). Vicarious trauma results in workers viewing their social world through a lens of suspicion and experiencing a diminished sense of control over events in their lives. A third manifestation of indirect trauma, compassion fatigue, is not unique to working with trauma survivors. As the term implies, compassion fatigue reflects practitioners’ inability to empathize with clients and can stem from the overwhelming needs of trauma survivors and the challenges they may present to workers as they attempt to engage and work with them. Research findings indicate that compassion fatigue is especially common among practitioners who work with trauma survivors (Harr & Moore, 2011; Knight, 2010). Indirect trauma is not the same as countertransference, although it may contribute to it. This is referred to as the indirect trauma–countertransference cycle (Pearlman & Saakvitne, 1995). When manifestations of indirect trauma are not recognized or addressed, this increases the likelihood of countertransference, which in turn intensifies manifestations of indirect trauma. The following examples illustrate how indirect trauma can compromise our work with clients:

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Tomas was placed in a men’s prison. One of his clients, Jerome, was incarcerated for assaulting a police officer and is serving a 15-year sentence. Tomas learned from his client’s record that Jerome had been sexually and physically abused by his father and his father’s friends. This included sodomy, forced oral sex, whippings with a belt, and being burned with cigarettes. Jerome also was mildly intellectually challenged. Tomas was asked to see Jerome after he was rushed to the medical unit following a brutal beating and rape by other inmates. Jerome tearfully described this most recent assault (he been raped on a number of prior occasions) and also described in graphic detail the abuse that he experienced as a child. Tomas discussed with his field instructor and in class how distressed he was about what Jerome had experienced, both as a child and in the present. He said he was having a hard time “letting go” of his feelings, an indication he was experiencing secondary traumatic stress. As Tomas further processed his session with Jerome, he realized that at some point, he just “tuned out” and was no longer listening to his client.

This was the first time that Tomas had encountered a client who had been so terribly traumatized as a child, and then again as an adult. As a new, young, and inexperienced social worker, he was particularly likely to experience indirect trauma—in this case secondary traumatic stress. Tomas’s reactions are understandable and expected. The challenge to him—and to any social worker faced with such client distress—is to learn how to continue to “be with” his client when the client’s experiences evoke such strong feelings. In this next example, a worker’s altered worldview—a manifestation of vicarious trauma—is evident in her fears about her daughter: At a workshop that one of the coauthors was leading on working with survivors of trauma, a participant, who had worked in Child Protective Services (CPS) for many years, described the difficulties she was having “letting go” of her toddler, who had just started preschool. She described how she was “certain” that something “bad” would happen “because there are so many perverts out there.”

This worker’s years of experience working with abused children and witnessing their physical and emotional pain convinced her that the world was not a safe place. In this same workshop, other participants acknowledged—with much self-reproach—that their altered views of their world angered them, and that this anger would surface in their work, particularly when they worked with children’s parents. One participant revealed, “I realize how much I dislike and distrust my clients’ parents. I used to be able to see their side of things, the trauma they themselves had also experienced. But now, it’s hard for me not to just see them as scumbags.”

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Table 12.2 Manifestations of Indirect Trauma • Vicarious trauma • Secondary traumatic stress • Compassion fatigue

These two examples suggest the ways in which indirect trauma can lead to interpersonal stress between worker and client. For instance, Tomas shut himself off at the precise time when his client most needed him to be emotionally available. The workshop participants’ altered worldview resulted in resentment that often was directed at their clients’ parents. This resentment could significantly undermine their ability to form the working relationships with these parents that were necessary to protect their child clients’ well-being. Table 12.2 summarizes manifestations of indirect trauma.

SOCIAL WORK FUNCTION, MODALITY, METHODS, AND SKILLS

When maladaptive client-worker interpersonal processes interfere with our ability to help, we must promote open and direct communications with clients and establish common stressor definitions. Ideally, this results in greater mutuality and reciprocity in our relationship. To do this, we rely upon methods that we have previously discussed in this book: enabling, exploring, mobilizing, guiding, facilitating, and mediating. Similar to understanding and addressing maladaptive dynamics that surface in groups and families, we adopt a transactional view of the interpersonal stressors and a willingness to examine our possible contribution to the maladaptive dynamics. This will require us to be transparent and acknowledge directly the role that we play in creating and maintaining the interpersonal stressors. The skills that we have previously identified are likely to come into play as we work to resolve interpersonal stress between our clients and ourselves. However, additional skills will be required as well, which parallel those that we employ when addressing maladaptive processes in families and groups. Our primary goal is to resolve the interpersonal stress, but our interventions in this area also may lead to deepening the worker-client relationship, enhancing client motivation and worker and client understanding of one another and themselves, and furthering the work itself.

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Viewing Maladaptive Patterns from an Ecological and Transactional Perspective

The first step to managing interpersonal stress is to identify maladaptive patterns using an ecological and transactional perspective. This requires us to identify both our own and our client’s behavioral contributions to the communication and relationship obstacles. For example, the worker realizes: “When John becomes quiet, I begin to talk too much”; “When Jane asks personal questions, I get flustered and change the focus”; or “When we have serious conversations, Billy begins to clown around, and I withdraw, feeling helpless.” Subsequently, we must explore our own feelings and attempt to identify what is triggering our reactions. For example, “When he is silent, he makes me feel like I am a terrible social worker. I would like to shake him to make him talk”; or “When he comes on to me, I get immobilized and don’t know what to do, and I withdraw.” Using resources like a supervisor, classmates, or peers, workers must develop ways to manage their feelings rather than to act them out. We also must use empathy skills (discussed in chapter 6) to anticipate our clients’ reactions to our verbal and nonverbal behaviors. In the first example, John may be thinking, “I didn’t ask for help. I am not gonna talk.” In the second, Billy’s reaction might be, “I’m just having some fun kidding around with her and she gets all panicky. What’s she learning in school anyway?” By owning their contributions to the interpersonal stressors in question, workers are more likely to feel empathy for the clients’ current situations and their affective reactions. Client preoccupation replaces self-occupation. Acknowledging the Pattern of Interpersonal Stress

When disruptions occur in our relationships with clients, they will not disappear unless we address them. The most basic skill involves pointing out the relevant patterns. This may require workers to identify specific behaviors that they have observed, as well as possible reasons that the interpersonal stress has occurred. Previously, we presented readers with the student social worker’s interactions with her client, Mrs. Peterson, who lost custody of her children and was court-ordered to receive counseling as a condition of getting her children back. She missed appointments and continued to deny any abuse of her children. In the session presented earlier, Mrs. Peterson’s anger at the mandate, as well as the worker’s impatience with her, were clearly evident and as the interview unfolded, their anger at one another only escalated.

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The worker had an opportunity to use the authority and power inherent in her position to encourage Mrs. Peterson to make changes that would allow her to regain custody of her children. However, this opportunity will be realized only if the worker directly invites a discussion of the client’s and her anger. In their next session, the worker would need to say something like this: I’d like to take a couple of minutes to talk about our last session. I must admit that I was frustrated that you were missing appointments and didn’t really seem all that interested in getting your kids back. I’m sure you could tell. And I could tell that you were angry—at having to meet with me, at me for getting upset with you. I don’t blame you. It’s tough to have to come here and talk to me when you don’t really want to and don’t think you need to. But if you do want to get your kids back, there are things that you need to do, and one of them is meeting with me to help you figure out what you’re going to do about your boyfriend, since social services determined that he did abuse your kids. I’d really like to help you with this, and I really do want to hear what you have to say.

At this point, the worker would then use many of the skills that we have previously described that come into play when working with mandated clients. As in family and group work, there may be times when we will need to continue to point out maladaptive interpersonal patterns each time they occur, as a way of challenging clients’ (and possibly our own) ambivalence, avoidance, and resistance. Their subtle nature, coupled with clients’ inability or unwillingness to acknowledge underlying causes of conflict, may require us to be persistent. In another example involving an abused child, the worker might say: Just now, I’m sensing—again—that we seem to be stuck. I bring up your feelings about us removing you from your mom and dad because we didn’t think you were safe with them [to a child just placed in foster care due to abuse], and you shut down. I know it’s a tough conversation to have, but I think it would help you to adapt to your new home.

Pointing Out Manifestations of Transference

When clients’ reactions to us are rooted in problems in relationships with others, the first step is to point this out to them in a nonaccusatory, nonjudgmental way. Because clients’ reactions may be unconscious, we may need to identify specific behaviors and reactions that we believe reflect underlying transference.

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Previously, we described the interpersonal stress that existed between the student worker, Michael, and Greta, a victim of domestic violence. Although not deliberate, Greta’s anger at her husband was directed toward Michael. Had Michael recognized this, he could have said something like, “I notice that you seem really angry at me. I’m wondering, though, whether the person you are really angry at is your husband? It’s risky for you to get angry with him, because he would retaliate and hurt you. So maybe it’s safer to express that anger toward me?” Acknowledging the Worker’s Reactions and Responses

Whether our reactions stem from issues in our personal lives or other factors, it is critical that we own them. Our clients will detect what we are really thinking and feeling, regardless of whether we communicate these reactions verbally. Therefore, if we are embarrassed about or uncomfortable with our client concerns, triggered in some way by their experiences, or angered or frustrated by their actions, they will recognize this at some level. Continuing with the previous example of Michael and his client, readers will remember that Michael’s reactions to Greta reflected his own feelings about his parents’ acrimonious divorce. His reactions served to exacerbate Greta’s anger. Had he realized this at the time, he would have needed to point out not only the transference, but also the countertransference: What I also notice [in addition to Greta’s anger at him] is that I haven’t been fair in how I’ve responded to your concerns about your husband. I haven’t been seeing things as you see them, from your perspective. You’ve been telling me how hard it is to stand up to your husband, how scared you are of him and his anger, and I just haven’t been listening. I’m sorry. But I’m ready to listen now. I hope you’ll give me a second chance.

This skill will require transparency on our part. When we discussed this skill in chapter 7, we noted that how much we disclose depends upon what will be most helpful to our clients. We noted that the research on use of self indicates that here and now disclosures, which reflect what is going on with workers as they interact with clients, are more helpful than there and then disclosures, which reflect workers’ lives outside of their work. Acknowledging countertransference involves a “here and now” disclosure, in which we reveal our feelings and reactions in the moment. It also may require us to issue an apology and an acknowledgment of our contribution to the interpersonal stress. In a previous example, we introduced readers to a hospital patient, Mrs. Charles, who was overwhelmed and stressed by her surgery (a hysterectomy), her

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resulting loss of income, and the high medical bills. The social worker also was overwhelmed by the depth of her patient’s distress, and as a result, she focused on collecting facts and getting things done, rather than on Mrs. Charles’s feelings. Had the worker been able to recognize this dynamic, she could have said something like: Mrs. Charles, I am so sorry. I realize that I have not been listening to what you are really saying to me and what you really need help with right now. I must admit that your distress is overwhelming to me, as I know it is for you. And I realize I have taken the easy way out and focused on what to do about it, rather than allow you time to talk about how you feel about it.

We must carefully consider how much to share when our reactions reflect traditional conceptualizations of countertransference. Consider the following case. Mrs. Billings is a victim of domestic violence, who expresses much ambivalence about whether she should leave her husband. Mrs. Billings frequently states, “It’s only when Simon [her husband] drinks that he’s abusive. If only he would stop drinking, everything would be okay.” The worker realizes that she has been dismissive of and impatient with her client, particularly when Mrs. Billings shares her belief that everything would be fine if her husband stopped drinking. The worker comes to understand that Mrs. Billings’s situation reminds her of her own ex-husband and his drinking and abusive treatment of her. In her next session with the client, the worker acknowledges her contribution to the interpersonal obstacle, but does not discuss in detail the reason for her reaction: Oh my goodness, Mrs. Billings. I am so sorry. I really do understand what a difficult position you are in. You’d like things to work out with your husband, but he hurts you, so you’re torn. I think my own feelings about your situation got in the way of my being able to hear you. Again, I am really sorry.

In keeping with the limited usefulness of “there and then” disclosures, there was no reason why Mrs. Billings needed to know why her situation triggered the worker—what she really needed was for the worker to acknowledge and apologize for her reaction and invite her to share her ambivalence. Recontracting with a Client

In each of the previous examples in which we have described how the worker can respond to interpersonal stressors, we actually are identifying opportunities for

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workers to engage in a “do-over” with their clients. We often have to deliberately discuss with clients how we can move forward and put behind us the interpersonal stressors that have created a disruption. Readers will remember Shana’s discomfort in her interactions with her client, Mr. Daniels, who had prostate surgery and was having problems with sexual functioning. Because both she and her client were uncomfortable talking about sex, her ability to be helpful and his to be helped were compromised. After Shana discussed this case in class, she came to understand what had gone wrong and how she could attempt to address the problem. Shana was able to get Mr. Daniels to come in for a follow-up visit, and opened the session by saying the following: I’m really sorry. I don’t think our last session was all that helpful to you. Talking about sex is never easy, particularly for a man, and particularly when he’s talking to a woman, particularly one who was kind of embarrassed herself (she smiles). How about if we start over? If we both try to put aside our embarrassment and talk openly about specifically what the sexual problems are that you’ve been having? If I can understand this better, I can be more helpful to you. I honestly don’t know if there are any solutions, but once I have a better idea of what exactly has been happening, we can start to explore if there are options available to you.

Each of these skills—used in combination with the many skills described throughout this book—will increase the likelihood that the worker and client will be able to move beyond the maladaptive interpersonal dynamics they are experiencing. As we have noted, they also increase the likelihood that both worker and client will learn from the disruption. Table 12.3 summarizes the skills associated with addressing interpersonal obstacles. As case examples have revealed and the practice illustrations given in the next sections demonstrate, engaging in these skills will require us to use skills previously discussed, including the following:

Table 12.3 Skills Associated with Addressing Interpersonal Obstacles between Worker and Client • Develop a transactional perspective and identify the interpersonal obstacles. • Acknowledge the patterns of interpersonal stress. • Point out transference. • Acknowledge the worker’s reactions and response. • Recontract with the client.

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Reach beneath the manifest behaviors and verbalizations. Invite and explore perceptions, content, and related feelings. Tune into the worker’s own feelings, as well as those of clients. Demonstrate genuine concern, warmth, and caring. Demonstrate an understanding of the client’s perceptions of self and situation. Invite the client to express perceptions of the working relationship. Acknowledge personal discomfort in the work on tensions and obstacles. Make supportive and persistent demands that obstacles be addressed. Demonstrate commitment to the work and the relationship. Pursue the client’s commitment to the work and the relationship.

The Importance of Supervision

Before we end this chapter with practice illustrations, we remind readers of the importance of supervision. Our helpfulness depends upon our willingness to seek out and use the support and guidance of others, beginning with our supervisors. Just as our clients need our help to resolve the stressors in life that are creating stress for them, we must be open to seeking guidance to enhance our competence and refine and expand our repertoire of skills. Supervision is the forum in which we refine and acquire new skills, as well as enhancing our understanding of ourselves and our clients. Our willingness to use supervision is essential to understanding the source of interpersonal stress in our relationships with clients and learning how to manage it. Readers may have noted that many of the case examples throughout this textbook refer to the worker’s discussions with a supervisor. Social work students will be supervised in their work. However, readers must anticipate that they are unlikely to have ongoing supervision once they gain professional experience. Therefore, we will need to develop our own peer consultation network. The need for supervision and consultation does not diminish as we gain more experience, but the opportunities to obtain it do. Supervision is only helpful to us—and ultimately to our clients—if we use it. Students and new social workers need the guidance of their supervisors to develop their skills as beginning social work professionals. Supervisors—and later peers—provide experienced workers with alternative, often new ways of viewing their work and their clients. Supervision also provides workers with the opportunity to examine their affective reactions and, as needed, help them manage them so they do not interfere with the work. Supervision is not therapy, and its purpose is not to help practitioners resolve personal problems. However, an important aspect of its educational emphasis is helping social workers

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identify and manage their personal reactions that have the potential to create interpersonal stress. Because indirect trauma is an ongoing challenge, workers must develop ways of managing its manifestations to minimize disruptions in the worker-client relationship. Supervisors, and later peers, play an instrumental role in this regard. Professional Methods and Skills and Practice Illustrations

Social workers must examine the source of interpersonal obstacles and acknowledge their own contributions. Unless we do this, we will be unable to reverse maladaptive patterns of communicating and relating. If the patterns continue, the client is likely to intensify resistance and testing behaviors or precipitously terminate service. “Listen to Me!” The Worker Realizes She Put the Agency ahead of Her Client Mr. French, a 45-year-old, single, white male, was admitted to a psychiatric hospital a month after being evicted from transitional housing after neighbors, other residents, staff, and relatives reported his “bizarre” behavior. Mrs. Houghton, his sister, brought him to the hospital. After six weeks, the treatment plan turned to encouraging the client’s return to the community, his job, and independent living, and required his participation in outpatient treatment. The hospital social worker met twice with Mrs. Houghton to collaborate on her discharge plan. In the first meeting, she met alone with Mrs. Houghton and Mr. French; in the second, the psychiatrist joined them. This meeting’s focus was on mobilizing coping resources for Mr. French. Mrs. Houghton tried to express her feelings about being responsible for her brother, but this was overlooked by both the psychiatrist and the social worker. The more the worker and psychiatrist pushed to focus on her brother, the more Mrs. Houghton resisted. By the third interview, the worker—who saw Mrs. Houghton alone—was more attentive to her concerns and anxieties. In the following excerpt, the worker and client discussed Mr. French’s unsuccessful attempt to visit a new transitional housing program: mrs. houghton: I hope your plan works; otherwise you and Dr. Murray will have to think of something else for my brother. He’s YOUR patient! social worker: I’m sorry that your brother was not able to go to the transitional housing place on his own. I guess it was an overwhelming task for him. We are

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still working on the plan we discussed. Maybe you could accompany him to look for an apartment. mrs. houghton: I won’t do it. I have leg trouble. I also don’t like to drive that far. I finally have my kids out of the house, my own job, and my own money. I’m at the point in my life that I only want to take care of my husband and myself, not my brother. social worker: I can appreciate the fact that you should have less responsibility for others, not more, at this point in your life. But can’t we explore ways that you can help your brother? You really are his only support system. mrs. houghton: But I’m concerned about my own mental health and I need to take care of myself [in the prior session, she had discussed her previous psychiatric outpatient treatment for depression]. social worker: But your brother is going to need some help transitioning back into the community. mrs. houghton (interrupting): I’m going to end up in this hospital myself if I have to do this all on my own! social worker (pauses): I’m so sorry. You’re right. Perhaps we could we talk about how you could help your brother and take care of yourself? Although your brother is our patient, I am also concerned about your well-being. I realize you are under great pressure due to your brother’s hospitalization. mrs. houghton: Thank you for your concern. I really do appreciate it. I am so stressed out! social worker: Maybe one thing that might help you feel less burdened is for us to talk about how you see your role with regard to your brother, instead of talking about how we see your role? mrs. houghton: I would like to invite him for holidays and occasional weekends to my home, but I don’t want to have to always check on him. If it comes to that, I would want him to go to one of the halfway homes that my cousin operates in Florida. social worker: That is an alternative, but your brother has spent his whole life here, so it provides him with stability and it’s familiar to him. Hopefully, we can work something out here. And that certainly means providing you with the support you need. mrs. houghton: Yeah, I sure could use it. social worker: Perhaps you might consider getting help for yourself? You can’t help your brother if you can’t help yourself first. mrs. houghton: I will contact someone if I feel I need it, because I know it can help. And I may have to do it. I can’t let my brother deplete me. social worker: Good for you. If you need help finding someone, I’m glad to do that.

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mrs. houghton: That would be great. Can we keep Florida as an option, just in case? social worker: Of course we can. It’s nice to know you have an alternative. But I’m hoping that if we work together and provide your brother and you with the support that you both need, we can work it out. Because I think you really care about him. You just can’t handle all of his needs on your own. And we don’t expect you to.

In this session, as in the prior ones, Mrs. Houghton let the worker know that she was overwhelmed by having so much responsibility for her brother’s care. Initially, the worker ignored Mrs. Houghton’s message and perpetuated the pattern of trying to convince her and “sell” the agency’s treatment plan. But she finally was able to move beyond the emerging interpersonal obstacle and become attentive to Mrs. Houghton’s needs by inviting her to talk about her pain, anger, and associated guilt. Mrs. Houghton could be an effective extension of the clinical team, but this would require that her feelings and perceptions be acknowledged and attended to, not bypassed or minimized. As this illustration reveals, when social workers empathize and respect family members’ autonomy and separate their needs from the client’s, the power struggle subsides and family members become partners in the care of their loved one. We’re Both “Micks”: The Worker Uses Common Heritage to Remove an Interpersonal Stressor and Deepen the Work

Mr. Kennedy, a 68-year-old Irish American widower, was forced to retire on complete disability because of severe diabetes. Because his Social Security payments had not started yet, Mr. Kennedy had no place to live, and he ended up in a homeless shelter after a fire destroyed his home and all of his belongings. After two weeks in the shelter, he was informed by a staff member that in another week, he would have to attend a hearing at the local Social Security office to determine whether he was in fact eligible for disability payments. The staff member said that she found him “abrasive” and “uncooperative.” Mr. Kennedy was angry, and he cursed and yelled that he didn’t intend to go to any hearing. He screamed, “You better let me stay here. I’ve worked hard all my life, paid my taxes.” He also threatened to “bash in the director’s head with one of my crutches.” After this outburst, he asked if the shelter could put him in touch with “a social worker woman like there was at the hospital.” He wanted to see her and see what she could do to “help me with all these damned people.”

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A social worker from the county’s department of aging was assigned to meet with Mr. Kennedy. Because he was on crutches, the social worker, who also happened to be Irish American, agreed to help Mr. Kennedy and told him that she would call Social Security to request a hearing at a more convenient location because of Mr. Kennedy’s physical condition. The hearing was relocated closer to the shelter, but Mr. Kennedy did not attend because he had not received notification of a change in the day and time. The worker had called to tell him of the change, and even dropped by and left him a note, but he never got the message. The following morning, Mr. Kennedy arrived at the worker’s office for the first scheduled interview. She recorded: When I asked why he had not come the previous day, he looked puzzled, pulled out a calendar with the date circled, and told me he was sure I had told him Friday. I explained about the change to Thursday and my effort to reach him by phone, and the note I left. I asked him if he received my note. He said he had gotten some paper in his box, but didn’t know what it was about and hadn’t read it. Mr. Kennedy became fidgety and looked quite uncomfortable. His face was red, he looked angry, and started yelling, “I am sick and tired of this bullshit. You are just like all the others, asking me to do things I can’t do for myself.” Thinking that he was referring to arranging the hearing, I pointed out that I had found an easier way for him, and all I asked him to do was to get himself to the hearing on the right day. Mr. Kennedy grabbed his crutches, stood up, glared at me, and blurted, “Look, you dumbass. I’ve been trying to tell you—I CAN’T READ!” As he walked out, he yelled back, “I don’t give a shit about the hearing, you can all go to hell!”

The worker acknowledged that she was angry with Mr. Kennedy for making her look bad and questioning her competence. She assumed that he was refusing to take any responsibility for his life. Moreover, as she struggled to control her anger, she became preoccupied with her own feelings, stifling her ability to be curious and listen. Consequently, she was unable to pick up Mr. Kennedy’s clues about his illiteracy. Mr. Kennedy’s frustration and anger were understandable: he was being held accountable for taking charge of his life when he could not read a simple note. From this interview, the worker became aware that Mr. Kennedy’s difficulties with agency personnel were not simply due to temper or hostility, but rather to his frustration, insecurity, and feelings of inadequacy. He used bravado to cover his insecurities. The social worker worried that Mr. Kennedy probably would not come back to see her. She wondered how to recover the contact and restart the dialogue, and what point of entry would mobilize his resistance the least. She remembered

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from their first contact that he had made numerous references to being Irish, and she decided that their common ethnic background might provide a necessary bridge. She paid a visit to the shelter, informed staff who she was and who she was there to see, and found Mr. Kennedy alone in the TV room. As she reported: When he saw me, he yelled, “Go back to your office.” I asked if I could sit down next to him, and he didn’t respond. I said, “Look, Mr. Kennedy, there’s a mick [a slang word for someone of Irish descent] standing here who can be just as stubborn as you. So, how about you let me sit down before the staff comes running?” With that, Mr. Kennedy laughed. “Well now,” he said, “I guess there’s still a little of the old sod in you after all.” “Well now,” I said, mimicking him, “I guess you are not the only Irishman who kissed the Blarney Stone either.” We both laughed, and he invited me to sit down. Initially, both of us were quiet. I broke the silence by saying, “I am sorry that I didn’t listen to you the other day and hear what you were saying, and sorry that I was angry at you without understanding how things really are for you. I really want to try to help you and hope you will give me another chance.” He immediately answered that if anyone should be sorry, it should be him, with his “trashy mouth and rotten temper.” He apologized for cursing at me and explained that he was so upset because it is hard for him to let anyone know that he can’t read. He told me he is very ashamed and feels like a “dummy.”

The worker effectively uses their common ethnicity as a point of entry into their interpersonal obstacle. Humor eased the tension and provided a boost to their working relationship. By apologizing to Mr. Kennedy for her insensitivity, she conveyed a willingness to risk further rejection. A transactional obstacle is best engaged when the interaction is between real people, who have strengths and weaknesses and struggle to come to grips with them and with each other. This encounter with Mr. Kennedy led to a major breakthrough in the quality and the depth of their ongoing work. The worker related: Mr. Kennedy spoke of having lost everything last year. I asked if he was referring to his wife’s death. He said when she died, he had nothing more to live for, that he wanted to die too. I asked him what got him through the worst days. He said he really didn’t know how he managed, but he just went through the motions of living, taking his insulin, preparing his meals, and trying to rest as the doctor ordered. He said he decided that if he didn’t talk about her and didn’t mention her name, it would seem like nothing had happened, that he could somehow keep her with him. He refused to talk to anyone about his wife, or about the circumstances of her death, or

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anything concerning her. I remarked that never talking about the one person who was so uppermost in his thoughts must have been extremely difficult for him. He looked very dejected, and he cried softly, “I can’t keep her with me, no matter how I try. She is gone. She is never coming back from the grocery store. I can’t make her come back.” I answered softly, “No, you can’t, Mr. Kennedy, but maybe you can begin to talk about her.” Later in the interview, when I asked him if he had ever tried to learn to read, he told me his wife was the only one who knew, and he was too ashamed to tell anyone else who might help. But now, when he had lost his wife and everything he owned, he said he had nothing else to lose. I asked, if he had nothing to lose, would he take a chance with me? I would like to help him learn to read. At first he was cautious, even resistant, telling me that it wasn’t my job and I wouldn’t know how to go about doing it anyway. Sensing his tension, I said maybe he was thinking about calling me a dumbass again. We both laughed, and that relieved the tension. I told him he was right, it takes special skills, and I knew a teacher with remarkable talent in teaching adults how to read. Before I could finish, he said he didn’t want a teacher treating him like he was a 6-year-old. I explained to him who this person was and that she taught many adults how to read. He agreed to give the idea some thought. The next time I saw him, we talked about housing. As we ended, I asked if he had given any more thought to my suggestion about his learning to read. He grinned at me and said, “Well you better call that old lady before we both get too old for her to teach me to read.”

With the social worker’s support, Mr. Kennedy took lessons and quickly progressed to a fourth-grade reading level. He seemed increasingly self-confident, smiling easily, getting along with shelter staff, and working with Social Security to obtain his disability benefits. Being able to read opened a new world for Mr. Kennedy and imparted a sense of mastery to him. The social worker’s progress with Mr. Kennedy was associated with her ecological thinking, an astute definition of the interpersonal obstacle, and total empathy. She defined the obstacle as being within her professional function. She owned her contribution to the obstacle, apologized, used humor to reduce tensions, and pursued Mr. Kennedy’s stake in working on his long-standing life issue. “I Don’t Want to Do the Stupid Life Book!”: Recontracting with a Client

Readers will remember from earlier in the chapter the story of Malcolm, the young boy who must complete a life book because the agency believed that this would ease his transition to his adoptive family. The agency assumed that

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Malcom’s life book should include his biological parents. Accordingly, the worker persisted in trying to get Malcolm to focus on his biological parents, despite his unwillingness to do so. In her peer consultation group, the worker describes the catch-22 she found herself in, as well as the interpersonal stress that this created between Malcolm and herself. Readers may note that the more she discussed this case, the more she understood the dynamics at play. As the worker reported: The agency does not deal with the reality that our services are mandated. They view the life book as the point of our work, rather than as a way to help Malcolm adapt to his new family. I feel tremendous pressure from the agency to focus on the “outcome” of our work—the life book—rather than the “process.” I realize I have been forcing the issue and not respecting Malcolm’s perspective, so he refused to continue the project. I now see that Malcolm’s view is that I continually nag him and bring up painful topics, which he had never agreed to work on. But then when he does bring up his anxiety or his unclear feelings, he (and I, really) just wanted me to “make it all better.” He did not want to sit with his painful feelings, nor explore or clarify them; he just wanted it all to go away. For example, Malcolm would be angry with his adoptive parents and would come to me to request another family. When I would try to get him to talk about his feelings, he would get angry with me. I was constantly disappointing him because I could not make the pain go away. My view has been that Malcolm was uncooperative, and I’ve had no choice but to keep trying to engage him and get him to talk about his biological family. I blamed him, and he blamed me. I’ve been trying to get Malcolm to do the life book, but totally ignoring his feelings. But I also identified with Malcolm’s avoidance of hurt and disappointment because it reminded me of my own childhood pain. I dealt with it the same way, by avoiding it. In protecting Malcolm, I’ve been protecting myself. I see two patterns. First, I initiate the subject of Malcolm’s feelings about either his biological family or his adoptive family, but do this in a very matter-of-fact way. That, of course, leads to him to avoid his feelings altogether, me trying to get him to talk about them, and then he and I both getting angry. Malcolm frequently told me he would never cooperate, and I was wasting my time by trying. So I would change the subject. And we’d go back to pretending we were working on his feelings and helping him adapt to his new family. The second pattern had to do with my inability to explore Malcolm’s feelings. He describes a painful event and comes into my office and expresses his anxiety by crying or wanting me to make it all better. Instead of acknowledging his pain, I was overwhelmed with the responsibility he was giving me and responded with rational explanations and superficial reassurances. I focused on completing the stupid life

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book, not the feelings that he brought to me. I tried to be empathic, but I falsely reassured him that everything would turn out all right one day, and gave him no tools to cope with the immediate issue. Although my emotions overwhelmed me, my external affect became logical and rational. My patterned reaction was to ask him factual, closed-ended questions and slowly refocus the interview on concrete, less threatening topics. Thus, we colluded to avoid emotional issues.

With the help of her colleagues, the worker devised a strategy to disrupt and modify the interpersonal stressor between Malcolm and herself. In their next session, the worker addressed the dynamic directly and recontracted with her client when Malcolm expressed his anger about his adoptive mother’s punishment for not doing his homework: worker: So you’re angry that your [adoptive] mom wouldn’t let you watch TV or play on the computer. That seems really unfair, uh? malcolm: I just want to leave her, I want another family that will be nicer to me. You all [referring to the agency] said I couldn’t go back with my real mom and dad. But then you make me go live with people who treat me mean! worker: It’s tough for you, isn’t it?Malcolm starts to cry. worker (softly): Your mom and dad hurt you badly, and it’s hard to get over that hurt even when you are with people who love you and want you. I know you’d like me to make it all better for you, but I can’t. I wish I could, I really do. But I can’t.Malcolm continues to cry. worker: I think maybe we need to try something different to help you feel better and feel okay about your new mom and dad. Could we try to do that? malcolm: Yeah, I guess. worker: Okay, so how about this. Let’s not focus so much on the life book . . . malcolm (interrupting): Yea! No more stupid life book! worker (smiling): So we agree on that! Instead of the life book, how about if we just take some time to help you talk about what it’s like being with your new mom and dad. The good and the bad. malcolm: Okay . . . worker: Sometimes it can be scary talking about bad feelings like being afraid or alone or angry. But you’ve been through a lot and you probably do have a lot of those feelings? malcolm: Yeah. worker: And they can be scary. But together, we can help you talk about that stuff in a way that’s not scary. Can we give it a try? malcolm (tentatively): Okay.

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worker: So, let’s go back to what you said earlier. You’re angry with your mom because she punished you. malcolm: She’s so mean sometimes! worker: No kid likes it when they get punished, that’s for sure. But I’m thinking she did that because she loves you. Wants you to do well in school. malcolm: But it’s not fair! worker: Life hasn’t been very fair to you, has it? Your real mom and dad hurt you and didn’t take care of you, and then you get new parents, and it’s scary being in a new family. malcolm: Yeah. worker: And maybe sometimes you worry that maybe your new family might not work out, either?Malcolm nods his head. worker: But you know what? It wasn’t something you did or didn’t do that led to needing to be removed from your mom and dad.

For perhaps the first time, Malcolm and his worker were talking and listening to one another. She abandoned the task of completing the life book and began to focus on how Malcolm had experienced losing his biological parents and then being adopted. She suggested that they reconsider how they will work together, and she models this by gently inviting Malcolm to explore his feelings. Given his age and the nature of their relationship, the worker did not need to go into detail about why the interpersonal stress existed. What was important was that she work with Malcolm to remove it. When the client and social worker work effectively on their maladaptive interpersonal patterns, they grow in confidence and mutual trust. Social workers need to view such obstacles as inherent in the helping process and struggle against discouragement and self-blame or blaming the client for them. Working together gives the opportunity for both participants to meet and master difficult challenges in creative ways.

Endings

THIRTEEN

Settings, Modalities, Methods, and Skills

Endings with clients can occur in a number of ways. In most cases, termination is planned and mutually agreed upon; however, clients end abruptly about 30 percent of the time. The primary reason that clients provide for ending abruptly is their dissatisfaction with the practitioner, the working relationship, and/or the process. However, practitioners attribute what is labeled as premature termination to clients’ “lack of motivation,” “resistance,” or both (Westmacott & Hunsley, 2017). Roseborough, McLeod, and Wright (2016) found that premature terminators were more likely to be oriented toward changing immediate stressors in their environment rather than themselves. Using anticipatory empathy and contracting skills more effectively, developing a clear focus and direction for the work, giving the client reminders of appointments, and developing a therapeutic working relationship—which includes openly dealing with any interpersonal stress between worker and client—lessen premature termination (Knox et al., 2011; Sharf, Primavera, & Diener, 2010). The risk of premature dropout also is reduced when clients perceive their worker as being culturally sensitive, and this includes acknowledging the differences between them (Anderson, Bautista, & Hope, 2019).

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The decision to end may be made jointly by the client and worker; it could be imposed by the nature of the setting, as at the end of the school year or at the end of hospitalization; or it might have been settled in advance, as in planned short-term and time-limited services. Occasionally, the decision to end comes about through an unexpected event involving either worker or client, such as illness, a move, or a job change. Whatever the context, termination represents an important transition and makes specific demands of both worker and client. These include (1) managing feelings aroused by the ending; (2) reviewing accomplishments and what remains to be achieved; (3) planning for the future, including, where indicated, transfer to another worker or referral to another agency; and (4) evaluating the service provided. Like the preparation, initial, and ongoing phases of practice, the ending phase requires social workers’ sensitivity, knowledge, careful planning, and a range of skills.

PREPARATION

Ending any relationship can be difficult. How many times have readers said, “See you later” to an acquaintance, coworker, or friend, knowing that this ending was in fact final? Endings may be painful, but at minimum, acknowledging and dealing with our feelings about them are awkward, and therefore avoided by many of us. For clients, the termination of a professional relationship can bring with it feelings of guilt, relief, and abandonment and reawaken feelings of loss associated with past experiences. Workers also may experience feelings of guilt, relief, or sadness when they end with clients. If the experience of termination and its meaning to the particular client are ignored or mishandled, any gains achieved in the work together can be lost. Future involvement with social work services also could be jeopardized. Handled well, however, termination results in growth for both client and worker. Ending is a mutual experience. The client needs to separate from the worker and the agency, while the worker needs to separate from the client. In preparing to help individuals, families, and groups move through the process of termination, social workers consider organizational, temporal, and relational factors and anticipate their likely impact on the client and on themselves. Organizational, Temporal, and Modality Factors

The agency itself influences the content and process of ending, particularly with respect to temporal features. Organizations differ in how they structure and use

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time. A public school, for example, has a natural temporal structure that fits well with both temporary separations and permanent endings. During holidays and vacation periods, temporary separations reflect natural pauses: the building is closed, family and friends may be more accessible, and time is available for other activities. A temporary separation is less likely to stimulate feelings of abandonment and rejection than separation that occurs in other organizational contexts. Temporary separation also provides clients with the opportunity to assess how they are doing without the assistance of the worker. Completion of the academic year carries the possibility of graduation and may be readily connected to a sense of progress and achievement, minimizing the sense of loss. In many settings—like long-term residential treatment facilities for the chronically ill, the elderly, and children and adolescents, and short-term institutional facilities—there are different temporal structures. When workers take holidays and vacations, this may be painful for residents, who already feel isolated and abandoned. The social worker’s absence may intensify feelings of desertion or create depression. There is no natural point of ending, like a graduation. Either client or worker might leave at any time. The client may be suddenly transferred or discharged, and the worker finds the bed empty. On the other hand, workers may be transferred or leave. The abrupt, often unexpected nature of endings in these settings makes them difficult. The temporal nature of the service itself also affects the ending phase. By definition, open-ended services carry no time limit or firm ending date. In longterm services, the working relationship intensifies over time and may reinforce client dependency and ambivalence about ending on the part of both worker and client. Workers must be prepared to introduce the possibility of termination even when clients have not recognized it themselves. Whatever the context, clients may experience shock and disbelief, perceive the ending as a personal rejection, and feel unprepared to live their lives independent of their worker. Planned short-term services have a specified duration, with an ending date clearly stated at the outset. The dynamics of termination in planned short-term services, therefore, are very different from those of open-ended services. Both client and worker mobilize their energy to accomplish specific objectives within the designated time period, and termination is an expected and planned-for event. Depending upon the length of service, the worker often needs to remind clients of their ending date as soon as the first session. An aspect of endings that is unique for social work students is the predetermined length of their time at their agency. In many cases, the student’s departure from the agency does not reflect the end of clients’ needs for services. Decisions about when and how to discuss with clients social work students’ departure

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from the agency should reflect considerations and use of skills that we discuss later in this chapter. However, it is essential that students inform clients at the outset when the internship will end when their work together will be ongoing. Otherwise, the students’ departure may be experienced by clients as arbitrary and ill timed. For this reason, agencies may refrain from assigning new clients to student social workers as their departure date approaches. Clients are likely to view students’ termination and their transfer as valid (though some clients do “forget” that they were told at the start) if they know the students’ status from the beginning. Students often struggle with ending with their clients, particularly when they believe that their clients continue to need their assistance. Students’ feelings may reflect their ambivalence about “deserting” their clients, as well as their understanding that their clients may not receive the same level of service once they are no longer there. Social work students often are able to provide more frequent and intensive services to their clients because their caseloads are considerably lower than those of agency social workers. Relational Factors

Intense emotions may accompany endings with clients when the working relationship has been ongoing and relatively long term. These can reflect the nature of the relationship, the context in which the ending occurs, and clients’ earlier experiences with relationships and loss. In this first example, the depth of the working relationship creates challenges as the clients prepare to end with their worker: The Meadows family was mandated to receive family preservation services from a private family services agency. This followed an investigation by Child Protective Services (CPS) that found evidence that the parents had physically abused their son, a 10-year-old with significant learning and behavioral difficulties. While initially reluctant to engage with the social worker, the parents ultimately acknowledged that they needed help managing their son. During their 16-week involvement with the program, the parents learned new parenting skills and ways of coping with his frequent emotional outbursts. The worker and the entire family developed a very productive and close working relationship. From the beginning, the worker clarified the nature and length of the services the Meadows family would receive. As their time in the program was coming to a close, the worker provided the Meadows with resources that they could use to help them “keep moving forward.” In their last session, the family and the worker identified gains

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they had made, as well as areas where the family could use additional support. The parents asked the worker if she could continue to see them. When she reminded them of the time limits of the program, they angrily confronted her, accusing her of “not caring” and interested only in “all the money” that she received for helping them. Despite her efforts to address the family’s feelings of abandonment and anger, their last session ended poorly, with the parents vowing that “they were done with social workers.”

The worker utilized skills that facilitate a productive ending, which we discuss later in this chapter. However, the family’s attachment to her—which had been essential to their work and the impressive progress they had made— ultimately made termination difficult for them. The worker second-guessed herself and her work, but she also understood that there might have been nothing she could have done to prevent the family’s distress. In this second example, it is the context of ending that leads to difficulties: The student social worker spent her yearlong field placement in a homeless shelter for men. The nature of the shelter’s services to clients meant that her work generally was brief and often ended abruptly when clients left, often without explanation. Because of this, the student assumed that there was no need for her to prepare her clients in advance for her departure. During her last week at the placement, the worker met with each of the six clients with whom she had been providing case management services and informed them this would be their last meeting. While two of her clients responded in a neutral way to her departure, the others expressed not just shock, but also anger at her for leaving with no warning.

The more sudden and unexpected the ending, the more difficult the management of feelings of sadness, abandonment, or anger are likely to be. Without adequate opportunity to work together on ending, the experience can be devastating for workers and clients alike. Consequently, work on termination may have to start in the first session (when the work is time-limited and short term) and be a theme in subsequent sessions. Termination can provide an opportunity to deepen the work on life losses, but it also can intensify clients’ unresolved feelings about past losses, as in this case: A social worker had been working with 10-year-old Jaden in a residential treatment facility. When the worker tried to talk about her upcoming departure from the agency, the client would talk to himself, sing in rhymes, and jump up and down in his chair. When the social worker attempted to gently break through Jaden’s avoidance by reminding him how many sessions remained, he withdrew into rhymes

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and refused to respond to questions or participate in conversation. The worker responded by assuring him of her affection for him. However, expressions of affection had accompanied the abandonment and betrayal of all the other “mothers” he had loved. Jaden’s response was to withdraw and protect himself from yet another loss. The social worker, like her client, felt powerless. She realized her responses often were triggered by intense feelings of guilt for abandoning him. She attempted to assuage her guilt and Jaden’s sense of betrayal by stressing that it was not her wish to leave. Her responses actually made it even more difficult for Jaden to express his anger at her.

Like many children and adolescents who have been removed from their homes, Jaden had experienced the loss of parents and all that is familiar—losses that he had not had the opportunity to process adequately. The loss of a client’s social worker, then, can activate deeply buried pain (Knight & Gitterman, 2018a; Gitterman & Knight, 2019). Anticipatory Empathy

Social workers prepare for the ending phase by considering what may already be known about clients’ previous experiences with loss and their means of coping with it. When such information is not available or known, social workers still can use anticipatory empathy to consider the potential impact that termination may have on their clients and themselves. With families and groups, potential reactions of each member must be considered, as well as the members’ collective response. In the following example, the student reflects on the impact that her departure may have on the group: I had been working with a group in a group home for adolescents, helping the members prepare for discharge and independent living. In trying to anticipate their possible reactions to my departure, I immediately thought of the deprivations, losses, and separations in their lives. I felt that I would be one more in a series of females who had left or abandoned them. The experience may be more difficult because of the life-transitional tasks involved in their impending separation from the group home. I anticipated some regression and tried to imagine how each member might deal with my leaving. Bill might reject me; Tony will probably show how much he needs me; Sam will most likely withdraw. I thought the group itself might avoid the idea at first, and then become disruptive. This might be followed in later meetings by absences or lateness. I planned to deal with avoidance of my leaving by persistently presenting the reality, impede flight by “chasing” absent or withdrawn members, and

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help regulate depression and anger by inviting and empathically acknowledging the intense feelings.

Social workers are also subject to painful feelings and reactions. We must, therefore, examine our own feelings about separating from a particular person, family, or group and our own patterns of coping with the stress of loss. We especially must consider the potential for guilt about leaving and the consequent difficulty in letting clients go. Without such examination, workers might deny the experience themselves. One worker might postpone announcing the ending date so that no time is left for helping clients process and sort out their reactions. Another might express ambivalence through indirect communications, ambiguous messages, or repeated postponements of the ending date. The social worker in the preceding example continues: I didn’t have to go far within myself to touch my own feelings. I am aware that I don’t cope with separations or endings easily. I know I tend to postpone the inevitable and to become detached. With these youngsters, I feel guilty about leaving them just when they are already confronting a major separation. I find myself wanting to avoid the issue, even blaming the agency, and needing to falsely reassure the group. Nevertheless, now that I am aware of these possible errors, I am determined to invite the boys to express their feelings. I hope that if I do become defensive, I can still reverse myself and allow them to explore and express possible feelings of sadness, disappointment, and anger.

By being in touch with their own patterns of coping with loss, social workers are better prepared to deal with their own feelings and therefore will be freer to help clients deal with theirs. Table 13.1 summarizes the factors that influence the termination process.

Table 13.1 Factors Influencing Client and Worker Reactions to Termination • Agency context • Professional status • Temporal nature of service • Modality of service • Relational factors • Client and worker backgrounds

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PHASES IN SEPARATION AND ASSOCIATED TASKS AND SKILLS

While responses to termination are unique to the individuals involved, most of us go through recognizable phases in ending significant relationships. Individual styles and pacing may vary, but it is useful to consider four phases that typically characterize the process. The phases are analogous to those observed in dealing with death, though obviously they are not of the same quality or degree. Kubler-Ross (1969), one of the first authors to identify the stages of grief (denial, anger, bargaining, depression and acceptance), assumed individuals went through fixed, sequential, and universal stages of dying. It is now widely understood that mourning does not necessarily follow predictable, uniform, and readily distinguishable stages. This is also true in the context of ending important relationships. The phases associated with ending relationships are avoidance; negative feelings; sadness; and release. Each phase has its own tasks, although not everyone goes through every phase or experiences them in the same order. Some people may not experience any of these phases, particularly when their encounters are brief. We now turn to the four phases that clients and workers themselves may go through. When our work is less intense or of shorter duration, these phases may be missing, compressed, or be experienced less intensely by our clients and ourselves. We discuss endings in these circumstances later in this chapter. The skills that we use to help clients end their relationships with us, and in groups, with each other are not new. Understanding the phases of ending assists us in using those skills in ways that enhance the potential for clients to engage in future social work services. Negation and Avoidance

The more satisfactory the relationship, the more likely clients are to ward off their feelings about ending by negating and avoiding its reality. Initially, some people “forget” that termination was mentioned earlier and try to avoid discussing it by changing the subject, or regressing to old, less productive behaviors. In the previous example of the Meadows family, the worker had prepared her clients for their last session each time she met with them. However, they would not discuss this reality. Avoidance can be adaptive when it provides clients time to absorb the meaning of the imminent loss and to develop means of coping with it. However, as the Meadows case reveals, clients may be unable to end with their workers in a way that is either productive or helpful.

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Similarly, the more satisfactory the relationship is for us, the more likely it is that we too will have difficulty with the reality of termination. Some workers can “forget” to mention termination until the last couple of sessions, leaving no time for their clients and they to process it. “Forgetting” may reflect workers’ feelings about ending and/or their desire to avoid addressing their clients’ reactions, which can include anger and sadness. A student social worker in a psychiatric facility for chronically mentally ill individuals had been working with Mrs. Miller, who, in addition to her mental illness, was deaf. He was the first person who had been able to engage her in a long while. She became dependent on him for concrete assistance. As his field placement was ending, she had been unwilling to accept the reality of his departure. For the last four weeks, she had been unable to acknowledge his written statements about leaving or about his interest in helping her to become more self-reliant and to use other resources. He described his most recent exchange as follows: Mrs. Miller greeted me with, “Where’s my toothpaste?” I wrote a note reminding her we had agreed she would ask an aide for this. She crossed her arms and scowled and said she liked having me help her more than anyone else. I wrote, “Because I’m leaving, it is very important for you to learn to use others, and I know how difficult that is to do. I want to help you with it.” She then placed six dollars on the table and asked me to buy her a Sunday paper. I realized she was holding on, struggling to keep our relationship intact. I wrote and suggested she ask the nurse to buy the paper, because I would be leaving and she had to get used to dealing with other staff. She crossed her arms again and looked angry. I wrote, “I like you, and this isn’t easy for me either, but I know you can do this for yourself.” She looked at me with a smile, and said she will ask the nurse. I wrote, “Maybe you can ask her when you see her on Sunday night?” She said she would ask her on Saturday so that she can have the paper on Sunday morning. I credited the idea, and then she began to cry.

The worker’s persistence and assurance of caring helped Mrs. Miller begin to cope with the stress of an inevitable ending. His ability to do this rested on his empathy and his awareness of his own difficulty in leaving her with so many helping tasks still undone. In contrast, Anna, a social work intern placed in a state psychiatric hospital, was assigned to Carl, a 15-year old who was admitted for exhibiting self-abusive, aggressive, and suicidal behaviors that could not be managed at his residential placement. The public child welfare agency had obtained custody of Carl and his siblings on the basis of severe parental abuse and neglect. Carl was a difficult

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youngster to reach, with a history of a high level of distrust and poor attachments. However, Anna was able to develop a close therapeutic alliance with him. Anna identified with and was committed to Carl and found herself avoiding discussing termination with him. Four weeks before the end of the semester, Anna’s field instructor brought to her attention that she had not introduced termination since the initial session. The field instructor discovered this only when she playfully teased Carl about “are you waiting until I’m your social worker again?” Carl responded with surprise, concern, and a lot of questions rather than the lighthearted banter she had expected. During a session with Anna later in the day, Carl initiated the discussion of termination in a very direct manner as the student’s process recording reveals: carl: You didn’t tell me that you were leaving. Phyllis [the field instructor] says that you’re an intern? A student? And you’re leaving. That’s true? anna: Yes, Carl. That’s true. I will be leaving in a month. carl: But . . . you’re the best social worker I’ve ever had. I hate this. anna: I’m sorry, Carl. I hate this also. carl: I have to work with someone else now? Can’t somebody just help me get discharged without me having another social worker? anna: I’m afraid not. When I leave, you will have Phyllis. I know you like her, and you know that she really cares about you. Phyllis is my supervisor and is aware of everything that’s been happening with you, and she will take good care of you. carl: Yeah, but Phyllis is really busy. She’s not gonna have that much time. And she’s . . . anna: She’s what, Carl? carl: I don’t know. You never told me you were leaving. What’s an intern, anyway? anna: Remember when we first met and in the first family session with your dad, I explained what an intern is—a student—and when I would be leaving? carl: I don’t know. I don’t think you ever told me. Maybe my Dad knows, but you never told me. If you did, I don’t remember. That was a long time ago. I thought you would be here until I leave—that I would leave first. anna: You’re right. It was a long time ago when we talked about this. It’s not fair that I let all this time go by without talking about it again. I’m really sorry . . . I was hoping so much that I’d get to be here when you leave, I think I pushed back that I was leaving too. carl: It’s not your fault. I probably spaced or wasn’t paying attention or something. anna: Maybe “fault” isn’t the best word. It’s my responsibility to be honest with you, and part of doing that is making sure you understand important things like when I’m leaving.

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carl: Well, whatever. It’s okay. So when exactly are you leaving? anna: The first week of May. carl: That’s only three weeks away! Can’t you stay until the end of May? anna: I’d love to be able to stay with you until the end of May or as long as it takes until you are discharged. But an internship is when a student works in an agency and learns how to be a social worker. When my school ends in May, the internship ends. carl: So this was part of school? Like you come here instead of going to class? I feel like a guinea pig or an experiment or something. Like I’m just somebody to use to see if you do good or not. anna: Carl, you are not “just somebody” to me. You’re a great kid, and I really care about you. All the progress you’ve made is because of how hard you’ve worked, not because of me trying to do well in school. carl: Well, you do everything really good, except when you get too serious about stuff and won’t let it go. Like “I think we still need to talk about . . .” (He proceeds to imitate me. He does a great job.) anna: (Laughing) Yeah. I do that—wow, you really got me good. How is that for you when I do that? carl: Frustrating! It’s annoying. anna: That feedback is very helpful. I will be mindful of that. Maybe you could let me know when you catch me doing that again. You know, Carl, this is a great example of how observant you are. Not every kid would be able or willing to help their social worker and also to let the social worker help him. As we prepare to end our time together, I’m hoping we can talk more about how we worked together and how far you have come.

Finding out from her field instructor that Anna was leaving, with no notice (as he saw it), created much stress for Carl. He assumed that his discharge plan would not move forward if Anna was no longer his social worker. Unfortunately, the way that he discovered Anna was leaving reinforced feelings of betrayal and abandonment that he already had in response to previous losses of adults upon whom he depended. However, Anna’s genuine apology and willingness to acknowledge her own feelings of sadness, coupled with Carl’s resiliency, allowed them to begin to do the difficult work associated with ending. Carl taught Anna about the importance of directness in the termination process, while the intern helped him to appreciate the strengths he possessed. Another social worker in a long-term chronic-care facility had successfully helped a group of elderly, socially isolated men with brain injuries engage with one another and with her. When she decided to leave the hospital for another

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employment opportunity, she could not tell her group due to her strong feelings of guilt. The worker recounts her experience: My plan for this meeting was to begin with my leaving, and somehow we actually did get onto the subject of loss. It would have been natural for me to introduce termination, but I chickened out—I just couldn’t. Mr. Jones was verbally rambling and suddenly brought out his pipe, which was broken in two pieces, and sadly said, “Look at that—that’s my only pleasure.” It took a while to establish that what was upsetting him was that no one could help him get a new pipe, though he had asked several aides. He exclaimed, “It isn’t too much for a man to ask, to have a smoke, there’s not much else.” After we established that I would help him get a pipe after the meeting, I asked if Mr. Kley and Mr. Dobbs had similar feelings about something they had lost and were sad about. They didn’t respond. I said that one thing that they all had in common was that they had lost part of their health. There was much nodding. Mr. Kley agreed, “Yeah—we all got sick.” I added the hospital was their home. Mr. Jones said they were all together in this, like neighbors. I asked why they thought we were getting together. Mr. Jones grinned and said, “The neighbors get together.” We all laughed.

Literally and symbolically, the worker moved back to the initial phase of work—and an agreement on the group’s purpose—instead of helping members transition to ending with her. Immobilized by her own feelings, she avoided introducing and dealing with termination. She tried again the next week, but she failed to anticipate the individual and group responses to her announcement: I said that by the middle of next month, I wouldn’t be able to meet with the group anymore, as I was leaving the hospital. There were nods but no one spoke. I said we talked last week about having things we like break or be taken away. I asked if they remembered. No one responded. After several efforts to get them talking about my leaving, there still were no responses. I said this is hard to talk about, or at least I find it hard. More nods, but the men just looked at me. I asked if it were on their minds that I will be leaving. Still nothing. I asked Mr. Jones if it is on his mind. He smiled and said, “That’s nice.” I was getting more and more uptight. I asked if the men would like to continue meeting with another worker after I leave. They remained expressionless and said nothing. I asked if they wanted to close the meeting, and they nodded affirmatively.

The worker’s avoidance of the meaning of the relationship evoked a reciprocal avoidance in the group members. They withdrew not only from her, but from one another as well. To be helpful, the worker needs to first tune into her own feelings about ending a significant relationship.

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Frequent reminders are often necessary so that the reality of ending remains on the agenda. With some client populations like children, the elderly, and those with developmental challenges, a calendar is helpful, with the worker crossing out each completed session and specifying the remaining number. Whatever the means used, the worker focuses on the issue, risking confrontation with clients’ pain and expressions of negative feelings. This process of working through negation is illustrated in a practice vignette from a 12-session school group of eighthgrade African American and Hispanic girls. As the social worker recounts: Keika reminded the group that next week was the last time we were going to meet before the holiday and asked if we could have a party during the last half of the meeting. I agreed that it would be fun and pointed out that today marks the halfway mark for the group. I suggested perhaps they would like to spend some time at the beginning of the next session to decide the focus for the remaining five meetings. Within a few seconds, the entire mood of the group changed. Most members seemed puzzled as they glanced around the room. Alice, Helen, and Maria, who were seldom at a loss for words, looked shocked. I waited several minutes, and then observed that they were awfully quiet all of a sudden, and I was wondering if my comment about having only five more sessions had taken them off guard. The silence just got louder. Finally, Ivory found her voice and demanded to know why I was cutting the group short when they hadn’t done anything “nasty.” Then she said that I had said I was going to be here until May, so what was the problem? Maddie explained in a “told you so” tone of voice that I just did not like them—that was the problem. I became flustered and defensive and reminded them that in individual interviews and at the first meeting, I had emphasized the group would meet for 12 weeks. Ivory retorted that I had said the group would meet for the entire school year, just like last year’s group. Inez shook her head and corrected her by pointing out that it had been changed to 12 weeks because too many people signed up. I affirmed that once their group was over, I would be starting the second group. Ivory angrily declared this was the first she had heard of it, looked around the group and loudly said, “I just want to get this straight . . . you are going to stop seeing us and start a group for those losers [referring to the next group of students]?” I responded this was very hard for all of us. There was an uncomfortable silence, and finally Maria said quietly that it seemed like we had just started and now we only had a short time left. I agreed, saying that we had come such a long way in such a short time, and it’s hard to end when the girls like coming so much. Keika responded that she was upset, but if I had taken the other group first, she would expect them to finish on time so her group would have a turn. Alice informed me I was going

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to need a bigger room to have a group with “those ho’s” because the only way they know how to talk is when they are lying down.

Persistence and assurance of caring helped the group members begin to accept the reality that it would end after 5 more sessions. By demanding that they confront the reality of termination, the worker helped the group to move into the next phase—expression of negative feelings. Negative Feelings

Negation and avoidance gradually give way to the reality of the ending through the social worker’s empathic support. Still, a period of intense reactions may follow. People express their hurt in many different ways, including direct anger at the worker, as previous examples have illustrated. We understand that readers may be uncomfortable with the thought of their clients becoming angry with them when they are ending their work. However, it is usually easier to address clients’ anger when it is expressed directly than when it takes a more subtle form. For instance, a physically challenged social work student had been seeing John, who had a long history of substance abuse disorder, for nine months. In her office, the worker had a footstool she used to help ease the discomfort associated with her disability. John usually sat down and hooked the footstool around so he could use it too. The sharing of the stool symbolized their shared work. However, in the session in which the student discussed termination, John kept the footstool all to himself. The student astutely pointed this out to John: “I noticed that you’re keeping the stool all to yourself today. I’m wondering if that reflects your feelings about our ending our work together?” Her observation opened the door for John to begin to discuss his reactions to her leaving. Others turn their feelings inward and experience the ending as a reflection of their unworthiness or the worker’s disappointment with them. For Phyllis, a twice-divorced woman who was the victim of interpersonal violence and also struggled with depression, the social worker’s impending departure triggered her chronic feelings of worthlessness and guilt. The worker, who was leaving the agency to take another job, describes the session with Phyllis in which they discussed her leaving: Phyllis began the session about being distressed over her forgetfulness. I asked what she meant, and she said she knew I had told her I was leaving, but she couldn’t remember why. I asked, “What’s running through your mind as you think about why I am

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leaving to take another job?” She said she had thought that sometimes staff takes other jobs when they get tired or are frustrated by their work. I asked if she was concerned that I might be tired of working with her and feel she hadn’t made much progress. She said, “Yes, My husband always said I was a loser, my parents always said I wouldn’t amount to anything. So I figure you probably feel the same way. I’m sorry, I’ve tried to work hard and get better. I really have.” I explained again that my leaving the agency was about wanting to work closer to my home, and then said, “It sounds like you think I am disappointed in you?” Phyllis started to cry, stating, “I really did try.” I replied, “Phyllis, you’ve done very hard and painful work. You’ve come so far. You have not disappointed me in any way. I think your feelings have to do with all the negative messages you’ve heard in your life from your parents, from your husband.” I continued, “Ending with you is very hard for me. Our relationship has meant a great deal to me.” She said that she had learned a lot from me and would miss me. I said I had learned a lot from her also—about a person’s courage to deal with grief and pain, to raise children without the help of a husband, to not allow men to batter her anymore. She said from our work together, she felt “like a fog has been lifted from me.”

Some clients may try to reintroduce needs or tasks that had been resolved or completed. They may regress, become excessively dependent, or in other ways attempt to demonstrate their need for continued service. Other clients may direct their feelings at their workers, accusing them of incompetence, lack of commitment, or both. They may confront the social worker directly, with accusations of lack of concern, or indirectly, with silence, repeated tardiness, or absence. The intended message is, “I’ll leave you before you leave me.” The behavior attempts to lessen the pain of the perceived abandonment and simultaneously to provoke responses from the worker that will further justify the distancing. In the following example, the school social worker addressed her client’s anger at her for leaving his school to take a job at another school. Vincent, a middle school student, had been seeing the social worker for behavioral problems that reflected trauma associated with having witnessed the murder of an older brother: vincent: Do you remember when I brought that rubber knife in here? worker: How can I forget? You and I got into a pretty big argument that day. vincent: (pacing the room, avoiding eye contact) I’m gonna bring that knife back in here. And I’m gonna pretend to hurt you real bad (smiles). worker: I think you want to hurt me ’cause I’m hurting you by leaving you in three weeks. You’re really mad at me. vincent: (moving to the farthest corner in the room and yelling) I couldn’t give a shit about you. You don’t mean anything to me. I’m mad at you, but not ’cause

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you’re leaving. I’m angry ’cause you’re a bad social worker and I’m bored. Can I go now? I’m never coming back even if you come trying to find me. I want a new social worker—one that’s nice. But would you come looking for me if I didn’t show up? worker: You bet I will. I’m not letting you slip out of my life so quickly (smiles at him). I won’t give up on you even if you think I am a terrible social worker. You have every right to be angry with me. If you want, you can yell at me for the next few weeks. But I won’t let you just not show up. I care too much about you.

Vincent wanted to hurt the worker where she was most vulnerable—her professional competence. He wanted to reject her before she could reject him. His anger served an important coping function; he fought back rather than opening himself up to feelings of sadness. Anger actually is a form of engagement—a kind of “ticket” to termination work. Even as clients experience and direct angry feelings toward their worker, they may simultaneously feel guilt at doing so. Workers, on the other hand, may respond defensively unless they can tune in to and appreciate the source of their clients’ anger. When we are able to empathize with our clients and understand the feelings that underlie their anger, we are able to invite and pursue their expression. In families and groups, the social worker must be sensitive to individual members’ expression of negative emotion. A session with a group of older adolescent residents in a group home illustrates the complexities involved. As the social worker recounted: I said it was hard to talk about my leaving. John said he was tired. He arranged three chairs together and lay down across them. He refused to look at me as he talked of how close he was to his siblings, saying they are the most important people to him since his mother died. He didn’t need anyone else, particularly not “some dumb social worker.” Bill was watchful and restless, and I asked what he was feeling. He said nothing but got up and left the room. Sam cursed at me and followed Bill out. I went after them and asked them to return. When the members were all back in the room, I said it’s difficult for us to talk about my leaving, but we have worked too hard to run away from each other. Sam screamed, “You have a nerve to open us up and then leave.” Bill yelled that he always knew I didn’t care. “We are just a job. You’re just like all the other social workers we know—a big phony.” George, who had been silent up to this point, said, “Yeah, you’re all alike. You make us talk about stuff and then you just walk away.” I said I knew how much they’re hurting, and I’m hurting, too.

In lying down, John was expressing his fatigue and depression while talking about important memories in his life; he negated the worker’s importance. In

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contrast, Bill withdrew and Sam acted out. The worker stayed with them, pursued Sam and Bill when they ran away, and helped all members explore their shared feelings of resentment. In these ways, she demonstrated her caring about them and her faith in their ability to work together despite their negative reactions. Endings often call for social workers to reestablish their credibility, skill, and commitment. A common error is a too-early expression of one’s own sense of loss, which can shut off the expression of members’ negative reactions. Sadness

As the reality of ending and resentment about it are confronted, clients and workers are free to experience shared feelings of sadness. Social workers encourage and support client expressions and respond to them by sharing their own sense of loss. They now can disclose the personal meaning of the experience and invite clients to do the same. Clients have varying capacities for such expression; for some, the practitioner’s recognition of unexpressed feelings may be relief enough. In other instances, the worker will need to reach for and be persistent in helping clients express their sadness. The worker with the group of elderly men in the chronic-care facility, described previously, helped the group experience together the sadness of leaving instead of continuing to withdraw from one another and from her: As I reintroduced my leaving, Mr. Dobbs burst into tears. He looked at me, then down, and shook his head. I reached across the table and put my hand on his; he continued to weep. I said I knew this was rough. He wept harder, and Mr. Lawrence reached across the table and patted his arm. Mr. Andrews watched with a blank expression. Mr. Jones’s eyes filled, and he said, “There’ll be nobody left for us.” I asked, “Are you worried that there won’t be any more activities?” He said, “Yes, ma’am, that’s what I mean. We need to do things.” Mr. Andrews and Mr. Kley nodded. As I mentioned the plans for another worker to take over, Mr. Dobbs began to weep again. I said, “Mr. Dobbs, we got close this year, didn’t we?” He nodded. I said I knew he and the others would miss me very much, just as I would miss them. They all nodded. I continued, saying that sometimes when people have to say goodbye, they feel very much alone. Mr. Dobbs said, “Yeah,” and pointed to himself. I said I hoped they wouldn’t shut each other out. They learned to care for each other, and they still have that. They looked at each other and nodded. I looked at Mr. Dobbs, and he responded clearly, “I understand, I’m with you.”

The worker acknowledged to members how difficult the subject of her leaving was for them and for her. She responded to their feelings verbally and with

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the intimacy of physical contact, which is important to these isolated and lonely clients. She disclosed her own feelings of sadness. Together, the members and worker felt the sadness and the closeness. The members also struggled to identify what the group experience had meant to them, and the worker located the strength in their situation: they have each other. Some clients express their intense sadness over the loss of intimacy by romanticizing the therapeutic relationship. For example, during termination, a young adult client, Calvin, informed his female worker: “I guess I love you.” When I pointed out that caring and love could easily become confused when two people develop a close working relationship and work hard together, Calvin said he must be “oversexed” and was ashamed for fantasizing about me. We then talked about what his feelings of “love” were, and he identified “gratitude, respect, honesty, and affection.” He explained, “I never let a woman get so close to me before. Jesus, we’ve never even shaken hands, and yet I feel we are so close.” “Yes,” I replied, “our minds have touched, our hearts have touched, and even our souls have touched, that’s made our work very special.”

Many clients may not feel such strong feelings of sadness but rather experience mild regret or unhappiness that the relationship is ending. While we must guard against acting on the assumption that our clients always will experience sadness, we also must be aware of clients’ attempts to cover up such feelings and to avoid the embarrassment often associated with their expression. Another social work student, Greg, process records a session in which he examines with his client, Ramon, his feelings about the student’s last session, which is the following week: greg: So, we’re at our second-to-last session. I know you haven’t wanted to talk about it, but I have sensed you are feeling sad about my leaving the agency. ramon: Nah, not really. I knew you were leaving ’cuz your internship is over. It’s all good. No worries. greg: Okay, so I hear what you’re saying, but you and I have been working together for a while now. We’ve been through a lot together, and you’ve come so far. Sometimes, particularly for us guys, it can be hard to talk about “mushy” things, like our feelings about saying goodbye. I know, at least for me, I’m going to miss you, and I feel sad that our time together is over. ramon: Yeah, I’ll miss you, too, man. I’m not sure what I would have done if I hadn’t had you to talk to.

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When Greg discussed this case with his field instructor, he expressed his worry that he was “seeking compliments” from his client or “overreacting” to their ending. Greg was able to see that his sharing his own feelings of ending gave Ramon permission to do the same, as did his validating that it can be hard for “guys” to talk about such things. While in many cases, it is more helpful for workers to share their feelings only after their clients have done so, in this instance, Greg’s disclosures were needed to allow his client to do the same. Both client and worker may avoid the awkward and sometimes painful discussion of endings, preferring instead to engage in fun farewell activities or some variation of a farewell activity. These sorts of activities may play an important role in ending the working relationship, but they cannot supplant the hard work that must come before. Table 13.2 summarizes the helping skills of dealing with the phases of avoidance and negation, negative feelings, and feelings of sadness.

Table 13.2 Phases of Separation and Worker Tasks and Skills Negation and avoidance

• Sort out one’s own feelings. • Provide sufficient time to allow for a period of avoidance. • Offer frequent and persistent reminders of the termination. • Refer to one’s own feelings. • Use visual aids such as a calendar. • Provide support and assurance of caring.

Negative feelings

• Sort out one’s own feelings. • Invite and pursue negative feelings. • Accept the expression of negative feelings. • Sustain the expression of client anger. • Avoid premature reassurance and power struggles. • Connect client behaviors and actions to unexpressed feelings. • Convey faith in the client and the professional relationship.

Feelings of sadness

• Sort out one’s own feelings. • Encourage and support expressions of sadness and regret. • Share one’s own sadness and regret. • Avoid escaping into happy activities.

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Acceptance and Release

Moving past negative feelings to reach sadness requires time. In the same way, moving through sadness to letting go of the relationship, to acceptance, also requires time. The worker leading a group of preadolescent girls had provided members with ample time to deal with separation. During each of the 10 sessions she had with them, the worker reminded them of how many sessions remained. Without that time, it is doubtful they could have reached the degree of acceptance demonstrated in the following excerpts: As soon as I mentioned my leaving, Nilda turned away and started looking at pictures on the bulletin board. She asked, “Who’s Joanne?” I reminded her that Joanne is the social worker who will be taking my place. Nilda turned from the board, insisting, “We won’t talk about her!”

For several weeks, the girls refused to refer to the new worker by name, and they avoided any discussion of her coming. But their curiosity and beginning acceptance finally generated some discussion: Lydia said she was wondering what would happen when I leave. I said Joanne is coming in to take my place. Lydia said, “But I may not like her.” I nodded, and she went on to say that if she doesn’t like her, she won’t come back to the group. Others agreed. I reminded them they hadn’t been too sure of me in the beginning, either; they hadn’t liked to talk with me much and whispered together instead. Lydia roared with laughter. With members’ acceptance growing, more open curiosity appeared the next week. Suddenly, Tata blurted out, “When is that other girl coming, anyway?” I said she would arrive in the beginning of August. She shouted, “We are going to kick her ass!” I said that didn’t surprise me. She added, “Well, you’d better tell her about us!” Nilda asked me if I had seen her and talked to her. I said I’d seen her a few times. Tata asked if I’d told her about them. Kathy said immediately, “Of course! What do you think they talk about?” I agreed, saying Joanne had asked me about them, and I’d said they might feel like kicking her ass at first, but this didn’t mean they wouldn’t get to like her. Everyone laughed, and I said I was serious, that this was just what I had told her. Judy asked me how tall Joanne is, and I said she was a little taller than me. Nilda exclaimed, “My God, another tall one,” and asked if she is older than me. I said, “No, younger.” Tata said she’d be too young to take care of them.1

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Little by little, over time, the new worker, Joanne, became a real person, with personal attributes and an interest in knowing the members. Once workers and clients have dealt with the varied emotions that accompany ending, they can turn to the final set of ending tasks: (1) recognizing gains and specifying remaining work; (2) developing plans for the future, such as transfer, referral, or self-directed tasks; and (3) final goodbyes, disengaging, and evaluating. Recognizing Gains and Specifying Remaining Work

In those instances when workers have been unsuccessful in helping clients work through the phases of ending, it is still important to help them reflect upon their work. This phase begins with workers inviting clients to consider where the agreed-upon focus and helping efforts now stand: “Let’s examine together what has and has not been accomplished.” Throughout the discussion, the worker emphasizes the client’s strengths and the gains made, but also encourages exploration of any areas of remaining difficulty. Mrs. Felstein, a 75-year-old resident in a long-term nursing facility, had great difficulty in adapting to institutional life. The student social worker, Teresa, had met with her for the entire 30 weeks of her placement and helped her to cope with the stress of unresolved life transitions and to make new connections in her social environment. In the next-to-last session, they reviewed their work together: teresa: I would be really interested in your thoughts about what you found helpful. mrs. felstein: You’ve helped me a great deal. I used to think you were too young and only a student, but I feel differently now. teresa: That’s nice to hear. Can you tell me what led you to feel differently? mrs. felstein: You listened to me. You made me feel like I had some choices, even though I didn’t want to live here. We’ve talked about so many things and I’ve come so far. teresa: When we first started, you talked a lot about your sister’s death and your guilt feelings. mrs. felstein: Yes, I still feel badly about that, but I no longer think it’s my fault. teresa: At that time you also felt pretty bad about the situation with your friend Dora. mrs. felstein: She doesn’t mean a darn thing to me now. I see her and she doesn’t affect me at all. teresa: I also remember how you felt you made the wrong choice in coming to our agency.

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mrs. felstein: I realize now I have to be here. It’s just not what I expected, but I guess I expected too much. teresa: I remember we talked a lot about this and about you trying to find a more comfortable role here. mrs. felstein: I don’t know if I can ever fully adjust to being here. I try to read more, watch the news, and do things I like. It will be very hard for me to get along without you. You’ve been a great help to me. teresa: I know it will be hard because we have become very close. mrs. felstein: Did I tell you about the community social worker who had originally developed the plan for me to come here? At first I thought the girl wouldn’t be able to help me because she was so young—I thought she’d never understand my problems, but then she turned out to be very dedicated. teresa: You thought of her in the same way you initially thought about me. mrs. felstein: (smiling) Yes. teresa: (taking her hand) I am sure you will feel the same way about the new intern. mrs. felstein: I sure will if they give me another young one. We ended our conversation by talking about how my supervisor will be available to her in the summer and will help her with the transition to the new student worker. I asked if she had some ideas of what she would like to work on in the fall. She said she has been thinking about getting involved with the senior center across the street and would like help in getting connected.

Plans for carrying on with the work, encouragement to complete tasks, and expression of confidence in the client’s ability to cope with life stressors can be combined with conveying the agency’s availability for future services as needed. The social worker helps clients find release by recalling together their shared experiences. This helps to clarify where client and practitioner were when they started, where they are now, and (when necessary) what new goals might be considered for the future. During this time, social workers also help clients to see the personal resources that they have rediscovered or developed for coping with the environment, managing life transitions, and other important areas of life. Earlier in this chapter, we introduced readers to the Meadows family. This family, particularly the parents, were unable to progress through the phases of ending, despite the worker’s weekly reminders of the ending date and her attempts to reach for their feelings. In a follow-up phone call two weeks after their last session, the worker finally was able to help the parents achieve release, despite their having been unable to acknowledge their feelings about ending

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other than their anger at her. While initially reluctant to speak with her, the parents—on speakerphone—begrudgingly engaged in a conversation that they were previously unwilling to have. The worker began her conversation with the following comment: worker: Thanks for taking my call. I was really troubled by the way we ended with one another. I was hoping we could maybe do that now, in a phone call. I understand you were angry with me for ending. I know you’ve had bad experiences with workers in the past, so thinking you might have to go through all this again with a new worker certainly could piss you off.The parents verbalize their agreement. worker: We worked well together, and you guys worked really hard.The parents verbalize their agreement. worker: So, you might be pissed off at me, and maybe a bit sad that our work is over, but you should be so proud of where you are now, where David [their son] is now. You deserve a lot of credit for that. All the credit for that. mrs. meadows: But we couldn’t have done it without you. mr. meadows: Well, yeah, things are better. worker: And the other thing is that even though you didn’t want to work with me, and were pretty pissed off when we started, you did work with me. And I think that’s because you wanted things to be better in your family. You wanted to understand David better and learn how to help him.The parents verbalize their agreement. worker: So, even though you didn’t want my help, you took it. And we had a great partnership. So, if you could do that with me, you can do that again. And I bet it won’t be as hard this time around because you know now what you need.

At this point, the parents and worker were able to talk about the gains that had been made, needs that the parents and their son continued to have that could require additional services, and resources that would be available to them. The worker’s willingness to reach out to the family once their case was closed might seem unconventional, but it was just what was needed to help the Meadows family achieve release and closure. The worker considered initiating an in-person meeting, but she determined that rather than promote closure, this might inadvertently encourage the family’s continued dependence on her. Her phone call, on the other hand, conveyed her genuine interest in her clients and provided one final opportunity for them to end their relationship with her in a way that reinforced their strengths. This also kept open the possibility that they could reach out to other helping professionals in the future if they needed it.

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Although the worker reported later that it was hard for her to do so, she ended the phone call by saying, “It’s been a pleasure working with you both and your family. I am so thrilled at how much progress you have made. I’ll remember with fondness our work together, and I wish you a happy life. Just remember, there’s always someone out there who can help you. I think you’ve learned you don’t have to afraid to reach out and ask for it when you need it. Goodbye, and I wish you the best.” Reminiscing and evaluating progress might result in the identification of uncompleted work. The social worker and client can identify areas for future work, either with another worker or with the client’s own personal and environmental resources. However, if the work can be accomplished in the remaining time, the social worker may develop an agreement with clients to work on the circumscribed area of concern. For example, Belinda, a student worker, was terminating with a nursing home resident, Mrs. Jacobson, who had a history of hospitalizations for depression and had great difficulty transitioning to the nursing facility. From the admissions record, Belinda learned that Mrs. Jacobson’s son had died in a “tragic home accident.” While she and the client had worked on other losses in her life, Mrs. Jacobson avoided discussing her son’s death, saying “He’s been gone a long time now,” or “Talking about him doesn’t change anything.” If the intern attempted to pursue her obvious unresolved grief, Mrs. Jacobson retreated into silence or proceeded with a rush of complaints about the quality of the food, the staff, and the facilities. After several months, Belinda stopped mentioning Mrs. Jacobson’s son, deciding that she had held on to her sorrow for 18 years since her son’s death, and that her coping efforts should be respected. In the third-to-last session, Mrs. Jacobson bitterly and repetitively complained about the nursing home staff. Belinda connected Mrs. Jacobson’s anger to Belinda leaving the nursing home. The following exchange occurred: mrs. jacobson: Why have you never asked me about my son? belinda: I never pushed you to tell me about him. It seemed like it was too painful for you. Would you like to tell me about him now? mrs. jacobson: Yes. He’d be 62 years old now. He was my first-born (becomes teary-eyed).Belinda reaches for Mrs. Jacobson’s hand. Mrs. Jacobson grasps her hand. mrs. jacobson: Why didn’t you ask me? Maybe I would have talked about it earlier. belinda: I wasn’t sure you wanted to, but I should have given you more chances. You are right. I am sorry. mrs. jacobson: I can’t even cry (teary-eyed). Belinda: You have held your feelings in for such a long time. You don’t have to any longer.

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mrs. jacobson: (crying) I’ve never talked to anyone about this before. I can’t talk to anyone like I can talk to you. belinda: Let’s talk about your son, and you won’t have to feel so alone with your grief. What was his name? mrs. jacobson: And maybe I won’t feel so angry all the time. (in a whisper) Larry. belinda: How about you tell me about Larry. mrs. jacobson: But you are leaving next week. belinda: I will be leaving in two weeks. Would you like to meet twice a week over the next two weeks so that we can talk about Larry? mrs. jacobson: Yes, please. belinda: How would it be easiest for me to get to know Larry? Looking at pictures together might help. Do you have any pictures of Larry that we could look at together? mrs. jacobson: Yes.She rummages in a drawer by her bed and produces a photo. belinda: What a handsome young man! Can you pull together some other photos of him?Mrs. Jacobson gets up, looks through other drawers, and finds several more photos. belinda: Ah, great! How about we go through them and you can help me learn about Larry’s and your lives together.

Before Belinda left, Mrs. Jacobson tested whether the intern had the ability to create a safe climate for her to explore her deepest and most buried hurt. While being perpetually angry at the world has helped her to deflect the sorrow, the grief has consumed her life for 18 years. The imminent loss of Belinda brought the pain to the surface. As the intern arrived for the next session, she noticed Mrs. Jacobson holding a large picture album: belinda: Last session talking about Larry was very emotional for you. How have the last few days been for you? mrs. jacobson: I have been thinking about him all the time. I want you to know that he committed suicide. No one outside the family knows. I’ve held this secret in for a long time. belinda: Wow, what a painful secret to carry all these years. I’m glad you could tell me. His suicide must have been devastating for you.

Ending with the worker increased Mrs. Jacobson’s sense of urgency to unburden herself of a painful family secret. As the worker and client perused the photo album, Mrs. Jacobson went into minute detail about the suicide of her

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son, including how she found his body. She required minimal encouragement to speak and simply unburdened herself, after 18 years of walling off her feelings. Through the photos, she introduced the intern to Larry as a baby and recalled his bar mitzvah and other special events like birthdays, holidays, and school graduations. She explained her remembrances, cried a great deal, and talked about his being special and her love of him. Mrs. Jacobson and Belinda both understood that the client’s grief work was not finished. During their last session, they developed a plan for Mrs. Jacobson to continue her work with Belinda’s field instructor. Because of the work they had done together, Mrs. Jacobson had a better understanding of what she needed help with moving forward, and Belinda’s skillful handling of her client’s indirect request for help provided her with the courage she needed to risk continuing her journey through her grief. Developing Plans for the Future

When termination is the final step and there are no immediate plans for clients to continue to receive services, workers and clients may choose to phase out their work together if that is possible. They may decrease the frequency and duration of sessions to every two weeks, and then to once a month. In addition, they may decide upon a follow-up and review after a few months. Whatever the arrangement, the social worker prepares the client to continue to work on any remaining tasks and to cope with expected and unexpected life events. Helping clients anticipate future challenges that they may face is empowering and enhances the likelihood that if such challenges surface, they will be better able to manage them. When continuing services are needed, workers help clients consider and then pursue available options. This can include transfer to another worker or referral to another agency. When transfer is required, the social worker attempts to involve the client in planning for this. Ideally, this includes an opportunity for the client to meet the new worker. This worker might observe a session, followed by another in which the departing worker and client summarize their work and specify future objectives. In the final transitional session, the new worker may assume primary responsibility. While not always feasible or practical, gradual transition helps minimize clients’ reluctance to start over with a new worker. When referral to another agency is required, workers help their clients plan for the initial contact with the selected service. If clients are to initiate contact, workers can help prepare them to deal with agency intake procedures and requirements. When workers initiate contact, they establish client eligibility and agency receptivity. When both the client and the agency accept the referral, the

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worker often provides information on the work with the client, professional impressions, and recommendations for continuing work. This requires that the client sign a release of information, which specifically allows the departing worker to share information with the agency and/or the worker who will be assuming responsibility for the case. As they end with one another, workers help clients think about how to present their needs and priorities to the new workers. There may be instances when the departing social workers may be able to participate in the first meeting with the new workers. While social workers may consider following up with their clients and the new workers to see whether they have connected well with one another, they must be sure that this does not undermine clients’ engagement with and trust in the new workers. Disengagement

Disengagement is the final phase of termination. Some clients may show appreciation through a gift to the worker. This natural desire needs to be respected and handled with sensitivity. In our judgment, there are no hard-and-fast rules for handling this situation, although some agencies prohibit the acceptance of gifts. Some gifts, such as money, a tip for rendered services, or an intimate apparel of clothing, clearly would be inappropriate because they blur the professional role. While the worker will need to decline this type of gift, this needs to be done with respect and a brief explanation for the reason. Similarly, at times, the worker might want to provide the client with a symbolic gift. The worker might take a photo of group members and then send it to them as a keepsake. A child welfare worker might take clients to a special lunch or visit to a zoo for their last session. In a setting for survivors of domestic violence, the worker might give the client a book of inspirational poems or sayings. Some clients may ask that our relationship continue on a personal basis. Others may ask for our telephone number or for a promise to correspond. Our clients’ natural desire to stay connected to us may parallel our own wish to stay involved with our clients’ lives. Most people want to give as well as receive, wish to continue a rewarding human relationship, and hope for some assurance that they will not be forgotten. These needs are neither problematic nor unusual. In most situations, however, it is unhelpful for us to agree to further contact. It has the potential to interfere with the client’s involvement with future social workers and is likely to lead to blurred boundaries. The following example illustrates the pressures for continued involvement as a school social worker attempts to help a young girl achieve release and a readiness to move on to new relationships:

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Sandy, age 17, lost both parents the year before. She now lives in the home of relatives who are heavy drinkers. Sandy and Janae, her social worker, focused on Sandy’s anger, guilt, and grief over her losses, conflicts with her relatives, her stormy relationship with her boyfriend and his subsequent rejection, and her future plans. Sandy knew from the beginning that Janae would leave at the end of the school year. Nevertheless, when the subject was introduced six weeks in advance, Sandy was devastated. Although unable to express her feelings about ending, she did use the remaining time to work productively on other areas of her life. Janae and Sandy decided on a picnic for their last meeting. Janae recounts the encounter: Sandy got into my car, and I immediately sensed she was in an uncharacteristic “up” mood, but it didn’t take long for her to become really quiet. I said that it was pretty hard to talk about this being our last day together. Sandy said, “Yeah, but I really don’t feel bad because I know I can see and talk to you on Facebook. We can be friends. So, I don’t really think of this as goodbye.” I knew I couldn’t leave Sandy with these fantasies. I acknowledged that her wishes reveal her caring, and then said, “You know, Sandy, this really is the end. This really is the last time we will see one another.” Sandy countered, “You talk like you don’t want to see me or hear from me.” Gently, I said, “I guess it sounds as if I don’t care, but that isn’t so. I care for you very much. We shared a great deal this year and have talked about so many important things. Now that it’s time to say goodbye, it’s especially hard.” She nodded her head in agreement. We then spent time talking about her feelings of rejection and how they were linked to past losses. I told her, “You know it’s easy to think that people—your parents, your boyfriend, your former social worker—come and go, and you have no control over it.” She added, “Yes, you’re right. What would you do if I telephoned you? Hang up? Or friended you on Facebook?” I said, “No, I would feel torn. I’d be pleased and happy to hear from you, but I’d know we still wouldn’t be seeing one another. That’s what’s hard to face, isn’t it?” She agreed. I said, “So, even though deep inside we know we won’t see a person again, we say, ‘Oh, I’ll see you’ because it makes it easier.” Sandy agreed. I gently told her that she will not see me again, but what we had together and what she learned was something she would always have with her. As we drove back to school, we were very quiet. Finally, I said, “Sandy, I don’t want you to leave until you have a chance to tell me what you are thinking. I hope you can say it now, rather than saying it to yourself later,” Sandy replied, “I’m going to miss you a lot. I just don’t know what it will be like not seeing you every week. I really liked you a lot.” She held back her tears. I said I felt the same way about her and added, “I know it’s hard for you. We’ll both feel very sad later as you go back

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Table 13.3 Skills of Helping Clients to Release • Invite review of the work together. • Emphasize the clients’ strengths and gains from the work. • Elicit a discussion of remaining areas of difficulty, if needed. • Review the work and the clients’ experience. • Develop plans to carry out the next steps: • For transfer, connect to a new worker. • For referral, find and link to new resources. • For termination, phase out the work. • Provide clients with the opportunity to say a final goodbye.

to school and I go back to my office, and we think about each other.” Sandy said, “I know,” and we hugged each other. Then she left.

As Sandy attempted to avoid the permanence of ending, the worker helped her to confront the reality. She affirmed Sandy’s feelings of abandonment and anger and responded, without defensiveness and with sensitivity, to questions about the genuineness of her caring. She helps Sandy evaluate her accomplishments and prepare for a new social worker. Her final invitation, to “say it now,” enabled Sandy to express her affection and to disengage with a sense of shared intimacy. Table 13.3 summarizes the skills of helping clients to release.

EVALUATING THE PROVIDED SERVICE

Endings are especially valuable in refining and expanding our skill set. Workers and clients jointly assess outcomes, identifying what was helpful and what was not, and why. This provides us with much-needed feedback and is empowering to clients. Many agencies require workers to complete—or have their clients complete—a formalized evaluation of the services. The client’s responses to questions provide a measure of worker and agency accountability. When the practitioner and agency take evaluation seriously, practice becomes more effective, services more responsive to need, and accountability to those served more assured. Creating a climate that permits clients to assess the services candidly is a measure of worker skill. Many workers and agencies, however, go beyond the ending phase in order to ensure accountability. Social work departments usually

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are included in the hospital’s questionnaire about total patient care. Many social service agencies mail out questionnaires after termination to assess client responses to the services. These strategies are valuable, as they can reveal attitudes and responses that clients may have hesitated to share with the workers. Workers themselves often follow up some time after termination to ascertain clients’ current situation and to determine if gains are continuing. Even though some suggest that this creates or prolongs dependency, we assert that follow-up demonstrates the continuing interest and goodwill of the agency and its concern for quality service.

VARIATIONS ON ENDINGS AND CHALLENGES

Thus far, we have outlined endings that occur under “ideal” circumstances, in situations when workers and clients have worked together for an extended time period. In many instances, though, the context of termination may be different from what we have described. Brief Encounters between Workers and Clients

In many settings, social workers’ encounters with clients consist of one session, as case examples throughout this book have illustrated. In those instances, emphasis in the final phase of that session would be on the tasks that we have identified in the acceptance and release phases. For example, a medical social worker tasked with discharging her client to a rehabilitation facility ends the interview with assurances that she will follow up with the facility to ensure that the client’s transition is smooth, and provides him with information that he will need upon discharge. She might end the session by asking her client for some feedback about how she did: Did she address his questions? Does he feel comfortable about his discharge plan? Is there anything else she can do for him at this point? A student placed in the victim’s assistance program within the office of the state’s attorney has a single brief, 20-minute meeting with her clients (victims of domestic violence who are in court to testify against the perpetrators) before the court hearing. During that brief meeting, there is little to no time to intentionally discuss endings. With her field instructor’s approval, the student develops a routine of following up with each victim after their appearance in court. While their meetings are very brief—usually only 5–10 minutes—the worker helps clients debrief from their court appearance, answers any questions they may have,

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and provides referral information and resources when needed or requested by her clients. Endings Imposed by Mandated Time Limits

In many settings, workers and clients meet for only a limited number of sessions—often fewer than 10 (Wodarski & Curtis, 2016). Workers and clients may form a close working relationship with one another, but it is likely that their feelings about ending will be less intense than those that exist when the relationship is more long term. A worker will still need to invite and encourage discussion of endings, but given the less intense nature of participants’ feelings, this discussion may come more easily, with less resistance and avoidance. When sessions are time-limited by agency or third-party requirements, workers and clients may have to address feelings associated with work left unfinished. The nature and pacing of the work should reflect the predetermined time limits. But workers and clients may still experience frustration at the perceived arbitrary nature of their endings. Enrique was placed in an outpatient drug treatment program. His client, Victor, was authorized by his insurance company to receive 12 counseling sessions. The agreed-upon focus of their work was helping Victor to begin to repair relationships that had been negatively affected by his addiction. During the course of their work, though, Victor disclosed several traumatic experiences in his childhood: the murder of a brother, the overdose death of his mother, and a house fire that left his family homeless. Enrique requested an extension from Victor’s insurance company, but this was denied. As a result, worker and client agreed that they would continue to focus on strengthening his social relationships, but they also would work on identifying a resource that would allow him to address his past traumas once his session limit had been reached. At the time of their last session, Enrique still had not been able to find an appropriate resource for his client—something that was deeply distressing both to Victor and him, as the following exchange reveals: enrique: I gotta tell you, this is really hard for me. I’ve really enjoyed working with you and am just so pleased at all that you’ve done. You know that, right? [Worker and client had been addressing their pending ending in the last several sessions.]Victor nods. enrique: It’s just so frustrating that we still haven’t been able to find a resource. You’re so ready to do the work! I’m so sorry that it’s taking so much time to get you the help you want and need.

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victor: That’s okay. . . . it ain’t your fault. enrique: I know, but I feel so badly that we are ending with no solid plan in place for you. I don’t want you to give up. victor: Yeah, it is sort of frustrating. enrique: It’s a lot frustrating to me! Even though we won’t see each other after today, I really hope you will continue to pursue the options I gave you. You’ve come so far, and I want to see you keep moving forward. Remember all that we’ve talked about? victor: (nods) I worked hard, man! Really hard! enrique: Yes, you did. You’re strong, you’re committed to putting the past behind you. If you can survive that, you can survive the runaround you’re getting right now. You know how to kick ass (smiles). victor: (smiles) Hell, yeah, I know how to kick some ass!

Soon after this exchange, Enrique and Victor said their final goodbyes with a hug and Enrique’s final words of encouragement for his client to “keep on truckin’.” With his field instructor’s approval, Enrique made several follow-up calls to Victor to see how he was doing and discovered that his client still had not found a new clinician with whom to work. After one month, he and his field instructor agreed that continued contact with Victor was counterproductive. As difficult as this was for him, Enrique realized that he had to live with the uncertainty of his client’s future. He continued to second-guess himself, wondering if he could have worked harder to secure a follow-up resource, but he ultimately accepted the fact that he did the best he could in a system that provided few options for clients with limited financial resources. Abrupt Departures of Clients

Earlier in this chapter, we noted that about one-third of the time, clients simply stop coming for their sessions. While this might occur in response to a planned ending and reflect clients’ avoidance, it usually occurs with little or no explanation. Research suggests that premature termination often reflects clients’ dissatisfaction with their worker, the process, or both, even though workers tend to attribute this to clients’ lack of motivation (Knox et al., 2011; Westmacott & Hunsley, 2017). In other cases, the termination is not in fact premature from clients’ perspective. Researchers operating from a solution-focused framework assert that clients may stop coming because they believe that they have benefited from their work and no longer need the help (Oliver & Charles, 2015). This possibility suggests that the worker might have more problems with endings than the client.

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In still other instances, clients stop coming because they are not ready for the additional help offered to them. Each possibility underscores the need for us to reach out to clients who abruptly stop coming, in an attempt to ascertain the reasons. Through a phone call, written letter, or e-mail—if this form of communication protects clients’ privacy— we can invite clients to share with us their reasons for leaving. We may suggest the possibility that we and/or our services did not meet their needs and ask for feedback that will help us improve our responsiveness and helpfulness to future clients. We also could suggest that even though the client might not be ready for our help at the present time, we hope that they will reach out to us—or others—in the future should that change. We also could inquire whether unforeseen circumstances contributed to their departure (such as an illness or job change). The following correspondence—a letter sent via regular mail—illustrates how workers can reach out to clients who abruptly end. The client, Mr. Reynolds, had been seeing the worker in a family service agency to help him deal with his recent divorce from his wife and the resulting estrangement from his children. They had met for six sessions and were planning a seventh one. The client did not show up for the next meeting and did not respond to telephone calls to his home. After three weeks, the worker sent the following letter: Dear Mr. Reynolds, I missed seeing you for your appointment three weeks ago and wanted to follow up to make sure all is okay. Since I was unable to reach you by phone, I thought I would send a letter the “old-fashioned” way. I am assuming that you have decided that you do not wish to continue meeting with me at this time. If this is not the case, please feel free to call me. Sometimes things happen that prevent clients from continuing with their sessions. If that is the case, perhaps, together, we can figure out a way for you to continue to meet with me, if that is your desire. I also have found that sometimes clients decide that their worker is not a good fit for them. If that is the case, I really hope you will consider talking with me. My clients’ feedback always helps me improve upon my work and my ability to help others. If I am not a good fit for you, perhaps someone else at this agency or somewhere else could be. I would be glad to help you with this. I do want you to know that I enjoyed meeting with and getting to know you. I respected that you assumed responsibility for your contributions to the end of your marriage and your children’s anger with you. That is an important first step to moving on with your life and reconnecting with your children. Perhaps you have reached a point where you want to take a break.

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Please know that I—or someone else at our agency—would be happy to meet with you again, should you wish or need to do so. Sincerely, Nina Wallace, Social Worker Midtown Family Service Agency

The worker did not have any idea why her client stopped coming and did not return her calls. Consequently, she offered several possibilities, including that he might be dissatisfied with her and their work together. If this was the case, inviting him to provide her with feedback not only helps her improve upon her work but also enhances the likelihood that he will reach out for help in the future. She left open the possibility that help was there for him if and when he wanted it. Unfortunately, Mr. Reynolds did not respond to the worker’s letter, so the worker remained unaware of the reasons for his departure. This sort of ending is understandably difficult for workers, and far from ideal. This social worker, like all of us, had to learn to put up with the ambiguity that comes with ending with clients, particularly those who leave without explanation. This is easier when we can look back on our work and accept that we did what we could and believe that if our clients need help again in the future, their experience with us will encourage them to seek it. We also must consider the contributions that we may have made to precipitating the client’s departure. “Beating ourselves up” over possible mistakes is not helpful, but using this knowledge to improve our work in the future can make abrupt endings easier for us to tolerate.

Life-Modeled Practice at the

PA R T I I I

Community, Organizational, and Political Levels

Part III of this book examines life-modeled practice that influences the quality of community life through engaging residents, advocates for needed policy and program changes in human service organizations, and uses political methods and skills to advance the cause of social justice. Almost a century ago, Porter Lee, in his 1929 presidential address to the National Conference of Social Work, noted that social work was moving away from a concern with a cause (social reform) and was assuming the character of a function (direct services). Like Lee (1929b), we believe that both cause and function are essential aspects of social work practice, and view it as a synthesis of empowering clients to manage their lives and their environment more effectively and productively and improving the environment’s responsiveness to clients’ needs and promoting social justice. However, the social work profession continues to be oriented toward function at the expense of cause. For the profession to fulfill its social justice commitment, community, agency, and policy practice must be carried out by social work practitioners in their day-to-day activities, as well as by practitioners who specialize in community organizing, legislative advocacy, and administrative change. Schwartz (1969) advocates for the merging of people’s “private troubles” with the macro “public issues.”

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In helping individuals, families, and groups with their life stressors, social work practitioners routinely encounter a lack of fit between people’s needs and the resources available in communities, organizations, and the broader society. The life-modeled practitioner must assume professional responsibility for mobilizing community resources to influence the quality of life in the community, for influencing unresponsive organizations to develop responsive policies and services, and for influencing local, state, and federal legislation and regulations to improve the lives of their clients. Part III deals with the expansion of direct practice activities from helping individuals, families, and groups to deal with life stressors toward influencing community and neighborhood life (chapter 14), practitioners’ organizations (chapter 15), and legislation, regulations, and electoral politics (chapter 16). We base our discussion in these chapters on two assumptions. First, workers engaged in direct practice have an obligation to address the broader social forces that affect clients’ lives. Second, strategies to effect social, environmental, and legislative change can be readily integrated into workers’ direct practice and build upon the skills we have presented throughout this book.

Influencing Community and

FOURTEEN

Neighborhood Life

The lack of community resources, problems with their coordination, and/or people’s difficulty accessing them may cause or exacerbate life stressors. Broader social, economic, and political forces like income inequality and institutional racism often are potent sources of stress in communities. To enhance the quality of community and neighborhood life, social workers in life-modeled practice must acquire certain knowledge and skills connected with community work. Generally, the social worker in life-modeled practice moves to the community modality because a significant stressor has arisen during work with an individual, family, or group that affects other community members as well. For example, a parent sought grief counseling to cope with the death of her child who was killed by an automobile because the street lacked a stop sign. The social worker discovered other accidents had occurred on the same corner and formed a community group to press for a stop sign. Social workers also use the community modality when they recognize a need and canvass the neighborhood or community to determine if the members share their perspective. In still other instances, workers engage with community members to help them prevent problems from occurring in the first place, gain access to needed resources, or create new resources.

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COMMUNITY AND NEIGHBORHOOD

The term “community” is most often defined as a geographically bounded locale recognizable by its location; natural boundaries; social, economic, and demographic patterns; and history. Communities perform certain necessary functions for their members, including the production, distribution, and consumption of goods and services; the transmission and reinforcement of prevailing knowledge, social values, customs, and behavior patterns that contribute to the socialization of residents; the use of social control to maintain conformity to community norms; and interactions through formal and informal groups to promote social connections. A wide range of public and private organizations and informal networks of individuals, families, and groups carry out these functions. Nonlocale communities are groups of people with a common interest, reference, or both who do not necessarily live in the same area. These include, for example, lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) and ethnic communities, professional communities, arts communities, and religious communities. The term “neighborhood” refers to a smaller geographic component of a larger community, defined by its locale. The immediate neighborhood is a potential place for intimate personal interchanges and informal support systems that can be important sources of mutual aid through the exchange of instrumental and expressive resources. For example, neighbors may offer babysitting services, provide transportation to a doctor’s appointment or grocery store, or help with home repairs. A neighborhood is more than its geography or its numbers. Some “neighborhoods” consist of residents that live in congregate units such as public housing, shelters, residential treatment centers, nursing homes, group homes, and the like. Contemporary Community and Neighborhood Stressors

Poverty and discrimination are major community and neighborhood stressors that create additional stressors. These social issues create unsafe habitats for residents and a preponderance of stigmatized niches, as well as undermining individual and community resilience. Community and neighborhood formal and informal structures are weakened or nonexistent, which further compromises the health, emotional well-being, and social functioning of its residents (Tompson, Benz, Agiesta, Cagney, & Meit, 2013). In some neighborhoods, residents have little or no contact with one another because of pervasive violence and a resulting sense of isolation. Residents of

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impoverished neighborhoods often have limited access to public transportation, which restricts their ability to access resources and initiate and maintain social connections. Some people living in poverty reside in cohesive, ethnically homogeneous neighborhoods that provide social integration and a sense of belonging and identity. But, many others live in “neighborhoods” that exist in name only. Numerous life stressors exist within poor communities and neighborhoods. These include the lack of affordable, safe housing; underfunded school systems; food deserts (i.e., the lack of fresh groceries in an area); limited opportunities for employment; asbestos and lead paint contamination in schools and dwellings; limited or nonexistent recreational spaces; drug trafficking and associated violence; and abandoned buildings that create blight and unsafe conditions. Inadequate systems of public sanitation and transportation (especially in rural and urban communities), inadequate health and mental health care, and unresponsive public and corporate bureaucracies generate additional life stressors. As described in chapter 2, poor communities and neighborhoods are more at risk of suffering from natural catastrophes, including hurricanes, earthquakes, floods, and fires, due to poor infrastructure and having fewer resources available to respond and bounce back (Adeola & Picou, 2014). Consistent with the Code of Ethics of the National Association of Social Workers (NASW), social workers should empower impoverished and vulnerable neighborhoods or communities to ameliorate some of these effects. However, the responsibility for the ultimate elimination of these stressors rests with society itself. This reality underlies the profession’s emphasis on community, organizational, and political advocacy to influence social legislation as integral aspects of life-modeled practice.

SOCIAL WORK FUNCTION, MODALITY, METHODS, AND SKILLS The Social Worker and Life-Modeled Community Practice

Different approaches to improving community life and members’ access to resources have been identified in the literature. They range from radical approaches, which seek to empower marginalized populations by redistributing wealth and resources, to collaborative approaches, which focus on strengthening community members’ ties with one another and helping them help themselves (Thomas, O’Connor, & Netting, 2011). Rothman (1996) identified three approaches to community practice, two of which reflect each end of this continuum and lend themselves to our

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life-modeled approach to social work practice. Locality development focuses on improving the quality of community and neighborhood life for residents. This approach to community practice focuses on residents themselves and may involve the following: 1. Helping community and neighborhood residents undertake action to improve the fit between available and desired formal and informal resources 2. Developing community programs and services to meet residents’ needs 3. Building informal community support systems of relatedness 4. Improving the coordination of community services

Social action focuses on helping marginalized and disadvantaged communities engage in collective action to advocate for changes in opportunity structures, the allocation of needed resources, and greater participation in civic, economic, and political life. In this approach, there are two targets of change. The worker first mobilizes community members to maximize the “power in numbers” that we first introduced in our discussion of the benefits of social work practice with groups in Chapters 6 and 11. The mobilization of community members leads to targeting social, economic, and political institutions and demanding that they become more responsive to and inclusive of community members. Rothman (1996) also identifies a third approach to community practice: social planning, in which social workers engage in research and fact-finding to delineate the nature of social problems and identify potential solutions. Residents are the beneficiaries of this approach but may or may not be involved in the effort. There are two targets of this form of community practice: the social problems that need to be confronted and the representatives of the social and organizational entities that have the power to make the needed changes. To illustrate these three approaches, let us take a problem that is pervasive in impoverished neighborhoods—rat infestation. A locality development approach might involve the following strategies: 1. Identifying and recruiting residents who are concerned about the rat infestation problem in their neighborhood 2. Helping residents organize a “trash cleanup day” 3. Helping residents identify and find resources to pay for items like ratproof trash cans and rattraps 4. Encouraging residents to develop an ongoing leadership structure that monitors trash in their neighborhood 5. Providing guidance and support to this neighborhood to take on future projects to improve the quality of life for residents

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When the social worker helps the community address the problem with rat infestation using a social action approach, the following strategies apply: 1. Recruiting residents who are concerned about the rat problem in the neighborhood 2. Helping residents develop a leadership structure to mobilize other residents for collective action 3. Helping residents identify government officials and offices that should be contacted to address the problem (e.g., sanitation services) 4. Assisting residents in developing and carrying out a strategy to persuade officials to correct the problem of rat infestation

A social planning approach to resolving the problem of rat infestation might include the following actions: 1. Surveying residents of a neighborhood with rat infestation to determine the extent of the problem 2. Identifying factors that contribute to the problem, as well as steps that are needed to resolve it 3. Ascertaining associated costs of alleviating the problem 4. Preparing a report of findings and recommendations 5. Presenting report to individuals who have power to correct the problem

For some community problems, one approach may stand out as being better suited to their resolution than the others. In many instances, however, social workers engaged in community practice may borrow strategies from one, two, or all three approaches. For example, one of our students was placed in a health clinic in an extremely impoverished neighborhood. A number of the patients, particularly children, had been treated for rat bites, and other patients were treated for health problems associated with contact with rodent feces. Both the clinic director and the social worker—who was the student’s field instructor—decided that the clinic needed to help community residents to address this problem. Over a four-month period, the student and her field instructor engaged in numerous activities, including the following: 1. Using patient health records, they identified the number of clinic visits that reflected a problem with rat infestation (social planning). 2. They generated interest among the clinic’s patients in addressing the rat infestation problem through their regularly scheduled appointments, phone calls to past patients, and flyers posted around the clinic (locality development and social action).

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3. They went door to door in the neighborhood immediately surrounding the clinic to determine residents’ interest in addressing the rat infestation problem (locality development and social action). 4. They hosted a meeting at the clinic for patients and other interested neighbors (locality development and social action). 5. They collected information from residents on their experiences with rat infestation (social planning). 6. They prepared a report documenting the problem, identifying solutions, and tallying associated costs and submitted it to the city’s sanitation department (locality development). 7. They arranged to have someone from the sanitation department meet with residents to discuss steps that they could take to resolve the problem (locality development).

The workers’ efforts resulted in residents taking more responsibility for cleaning up trash and monitoring their streets and alleys. However, the staff and residents identified several barriers to resolving the problem. Many residents did not have the money to purchase ratproof trash cans. A number of the properties in the neighborhood were abandoned and used as dumping sites. Most of the residential properties were rentals, and landlords often did not provide trash cans to their tenants. Sanitation workers assigned to conduct “rat patrols” did not do their job, and code enforcement officials were not citing landlords and owners of properties for trash, as required by law. To tackle these barriers, the workers transitioned from primarily a locality development approach to one oriented toward social action. The social workers initially focused on helping community residents to help themselves. When external barriers arose that prevented residents from successfully doing this, the workers realized that they needed to adopt an approach that would compel city officials to do their job. In many instances, a community must attempt to resolve its social problems before adopting a social action strategy. Table 14.1 summarizes the three approaches to community practice. Helping Community Members Undertake Collective Action

Engaging impoverished and vulnerable community residents in a collective effort to empower themselves and to achieve their desire for social change is a significant professional objective for the life-modeled social worker. Community practice often results from workers’ experiences providing direct services to clients.

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Table 14.1 Approaches to Community Practice Locality development

• Improve the quality of life for community residents • Focus on community members themselves Examples: community garden, neighborhood cleanup program, neighborhood watch

Social action

• Community members working collectively to improve opportunities to engage in civic, political, and economic life • Focus on mobilizing community members and on targeting social, political, and economic institutions to improve their responsiveness to members’ needs Examples: public housing residents demanding repairs; neighborhood residents demanding more police patrols

Social planning

• Engage in fact-finding and research to document the nature and extent of social problems, and solutions for them Examples: assessment of health needs in a neighborhood; ascertaining the need for and interest in an afterschool program for teens

Consider this first example of a worker’s efforts to help a community develop a needed program. A social work student at a public welfare department worked with individuals and families from a rural unincorporated community of some 2,600 residents. The community had one of the highest percentages of low-income families receiving Temporary Assistance for Needy Families (TANF) in its county, one of the highest referral rates for child abuse and neglect, and the highest rate of teenage pregnancy. Yet no support services were available except for a monthly well-child clinic conducted by the Visiting Nurse Association (VNA). Any other formal services were 20 miles away, in the nearest small city, but lack of public transportation was a formidable barrier. The social worker and her social work and nursing colleagues on the interdisciplinary Suspected Child Abuse and Neglect (SCAN) team decided to work on mobilizing and strengthening natural or informal helping systems. Interested members of SCAN formed an independent task force, the Rural Community Resources Group (RCRG), to help the community develop its own informal resources. Data were gathered to assess the support and participation of influential members of the community and for preparing a request for grant assistance.

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The social worker familiarized herself with the physical layout of the community and its social structure, demographic composition, and norms and values. She called on prominent residents, spoke at meetings, and met regularly with an informal mothers’ group that already existed, as well as with other members of RCRG. She also obtained data pertaining to teenage pregnancy, child abuse, and neglect. Almost all town residents participated in the needs assessment, which was carried out by volunteer mothers who went door to door canvassing residents and eliciting their concerns and suggestions. A total of 10 mothers, including some from the VNA group, and some protective service clients met weekly with the RCRG for two months. There was immediate agreement on the goal: a drop-in parent-child center where preschool children could be cared for a few hours a day or week and where mothers could seek information and find a sympathetic ear. Both respite and improved parental functioning were seen as desired outcomes. The mothers and other residents again canvassed all community residents using a questionnaire to elicit ideas about, support for, and advertise the proposed drop-in center. Additional questionnaires were left at the two grocery stores in the community, the free swimming pool, and the local physician’s office. The mothers made and distributed posters, and a news article was written and published in the local free newspaper. The student reported: The town’s director of Community Development assisted us in locating vacant sites. We undertook a search for seed money along with community residents, approaching the officers of the local bank, businesses, and civic clubs for donations. I approached the State’s Public Welfare Department, which has a new grant for direct services in rural areas, and administrators agreed to accept a proposal from us.

The drop-in center for mothers and their preschool children opened in September and was located in the fellowship hall of a local church. A grant of $25,000 from the governor’s comprehensive children’s and youth project supported this center and one in another rural town. Both centers were open one morning a week, providing self-planned programs and discussions for parents, childcare, and transportation services. The programs were later extended to two mornings a week as interest grew. An inevitable question is: how can an already overburdened social worker spare the time that community practice requires? The student’s comments in this regard are insightful:

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The first problem I encountered was how to convince my immediate superiors that any time involved would eventually be worthwhile for our clients. There has only been intervention on one level, after the fact of abuse or neglect, and preventive services are nonexistent. The Department of Public Welfare has never hired a community worker nor moved into group services, so any new services would require administrative approval. Because I’m a student, though, this didn’t matter.

Many agencies now view the community modality as part of their practitioners’ responsibilities. In an agency that has not yet embraced this view, however, life-modeled practitioners need to gain the approval of the person to whom they are accountable for time spent in community work. Community practice often focuses on a particular social problem, such as rat infestation, but it always should have as underlying objectives promoting feelings of self-efficacy among residents, their sense of connectedness to one another, and opportunities and motivation to engage more effectively in social, economic, and political life (East & Roll, 2015). Residents are more likely to become involved and take action when they have identified an issue of immediate concern and importance to them. A fundamental principle of life-modeled community practice is that issues must reflect residents’ sense of urgency and priorities. In engaging community and neighborhood residents to undertake collective action, the social worker carries out five essential tasks, discussed next. Assessment of Community Needs and Strengths

The social worker begins with a needs assessment. Two approaches to ascertaining a community’s needs have been identified (Bezboruah, 2013). In a bottom-up approach, the need for collective action arises from within the community. In a topdown approach, individuals from the outside—often individuals who interact with and provide services to residents—are the first to identify a social problem that requires collective action. The previous example of the student’s participation in a community effort to combat rat infestation reflects this top-down approach. Most social policy approaches to community change also reflect a top-down approach. As an example of a bottom-up approach, a student placed in an inner-city high school helped students’ parents advocate that a public substance abuse treatment program extend its services to adolescents. A substance abuse treatment program was located in the neighborhood that provided services free of charge or for a nominal fee, but the program restricted its services to adults.

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The only local and public treatment program for adolescents was inconveniently located, and therefore difficult for them to access. The social worker learned of parents’ complaints about the lack of readily accessible resources for their children through her interactions with families of her clients (students who had substance abuse problems). We expand upon this example later in the chapter. Whichever approach we adopt, we interact with the community with humility and respect. Consistent with our discussion of cultural competence and sensitivity to diversity, we convey to community members that they are the experts in their lives. Our role as professionals is not to tell them what to do, but rather to assist them in identifying what they need help with and how working collectively enhances the likelihood that their efforts will be successful. The ultimate goal of all life-modeled community practice is to improve residents’ quality of life. As participants work together toward their avowed objectives—with the guidance of the social worker, as needed—their competence, self-direction, cohesiveness, and sense of community pride are enhanced. The assessment will be tailored to the specific stressors facing a community and the practice context. However, the types of information that might be collected include: • • • • • • • • • • •

Physical layout of the community/neighborhood Demographic characteristics of residents Formal and informal leaders Existing organizations and services Members’ motivations to work collectively Values and norms Political structures Financial and other resources Residents’ views of stressors Sources of intracommunity tension Community history

Information can be obtained in a variety of ways, including talking to residents—particularly those who hold influential roles within the community—and church and civic leaders; conducting formal surveys; and collecting factual information from educational, medical, social service, and law enforcement sources. This information allows the social worker to develop an initial understanding of community and neighborhood dynamics and the stressors that collective action must tackle, but also the resources available to do so and potential obstacles.

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A social worker and her colleagues employed by a hospital’s methadone maintenance program were concerned about the lack of community acceptance, negative attitudes, and discrimination experienced by their clients. While methadone maintenance helped clients maintain their sobriety and steady employment and reestablish meaningful relationships with others, they reported feeling misunderstood, stigmatized, and discriminated against. In a recovery group led by a social worker in the program, members shared their experiences of being verbally harassed by residents living near the clinic and expressed worries that their employers would fire them if they learned that they were in the program. Based upon members’ stories, the social worker, with the assistance of other clinic staff, decided to collect information in a more systematic way. She developed a brief, informal survey that she distributed to all clients through their counselors. The survey included questions about clients’ work history, their experiences with discrimination and hostility in the community, and their perceptions about barriers potential clients might face in seeking help from the clinic. More than two-thirds of the clinic’s patients completed the survey, and the results documented patients’ fears of losing their jobs, experiences with discrimination in seeking employment, and their reluctance to share their enrollment in the treatment program with their health professionals. The majority of patients also reported experiencing negative community attitudes and knew others who were fearful of receiving treatment because of the negative consequences. To assess the actual or perceived negative community attitudes toward methadone maintenance generally, and her program specifically, the social worker set out to collect information from the community itself. One source entailed a review of the local newspaper, where she found headlines like “Neighborhood Tenants Say They Are Unhappy About the Proposal for a Methadone Clinic Nearby Because It Would Add to Drug Traffic in the Area” and “Neighbors, Parents Protest Rehab Center.” The worker also assessed employer attitudes through a brief survey of 10 local merchants in the community. The data collected from this small sample confirmed that most of the potential employers in the area expressed negative attitudes toward individuals being treated with methadone. Interviews with long-term community residents and organizational and political leaders provided the worker with additional data. She discovered that the closing of a residential treatment program significantly affected the chemically dependent population and the local community. Homelessness increased, as did the prevalence of drug abuse, which in turn negatively affected community attitudes toward drug addiction and those struggling with the problem. The closing of a factory, which was a major community employer, represented another significant event that created a large loss of jobs and marked the

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beginning of an economic shift in the community. Unemployment increased, housing values decreased, and a sense of hopelessness and despair became pervasive. Several long-term residents associated a significant increase in substance abuse to the closing of the factory. The anecdotal, survey, and interview data documented the lack of community acceptance of methadone treatment and the serious ramifications that this lack of acceptance had on clients and their need for comprehensive services. The social worker and other clinic staff identified and recruited key community leaders who they believed would be helpful in alleviating the negative stigma and increasing community acceptance of methadone treatment. This included the mayor of the city, who had previously expressed support for the methadone maintenance program; religious leaders who provided space in their churches for Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings; and local doctors who served the community. Based upon all the information that had been collected, the community intervention that the worker and her clinic undertook was one of outreach and education. We elaborate upon this case later in the chapter. Mobilizing the Community

The previous example illustrates an approach to community practice in which professionals play a central role in the effort—in this instance, to modify a community’s views of and responses to a marginalized group (namely, substance abusers in a methadone maintenance program). It also illustrates an approach that relies heavily upon social planning. Clinic staff did their homework: they identified the nature and scope of the problem, developed and implemented a strategy to address it, and evaluated the impact of that strategy. Community practice often requires significant involvement by community members themselves. The worker serves as a catalyst, but the residents, and the power inherent in their numbers and their collective action, bring about social change. Three tasks are involved in mobilizing community members, as described next. Identify and recruit influential community members. An important aspect of the worker’s assessment of a community’s needs, strengths, and resources is identifying key players. These are individuals who are held in high regard and have influence due to their formal role (educators, clergy, medical personnel, and merchants) or informal role (long-term residents, parents who open their homes to their children’s friends, and individuals who perform errands and help their neighbors out with home repairs). Depending upon the purpose of the

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community intervention, the social worker also may need to recruit representatives of institutions and organizations who could be instrumental in the community’s collective change efforts. Mondros and Wilson (1994, pp. 43–49) suggest three characteristics of effective recruitment: (1) natural networks, (2) representativeness, and (3) special individual attributes. Tapping into natural networks is an expedient method for recruiting community and neighborhood residents. For many people, the trust, familiarity, and support provided by natural networks encourage their involvement. For instance, the social worker might consult with a resident, who then introduces the worker to relatives, friends, and neighbors or contacts them on the worker’s behalf. Natural networks and helpers may be found in congregates such as public housing, some workplaces, and churches. Some children and teenagers are natural helpers to their peers. Other natural helpers include beauticians, bartenders, storekeepers, pharmacists, building superintendents, waitresses, and restaurant operators, who are alert to the well-being of their elderly, physically challenged, cognitively impaired, or depressed and anxious customers. They listen, empathize, and offer concrete advice and reassurance. In the example of parents’ efforts to obtain substance abuse treatment for their adolescent children, the worker began by asking the parent of one of her high school clients if she could identify others who shared her concerns. This parent contacted several of her neighbors, as well as her sister, who also had teenagers. In turn, the sister and several of the neighbors contacted additional individuals. This informal means of recruitment resulted in an initial meeting that included 15 interested parents. The initial recruitment effort resulted in a group of residents who had an intense commitment to the community problem. Research suggests that when community members are personally affected by a social problem, their motivation and commitment to address it is enhanced, and this enthusiasm is likely to spread to others who may have little or no direct experience with the issue (Christens & Speer, 2011; Walker & Stepick, 2014). The worker must consider the necessity of informed consent when community members have a personal investment in or are directly affected by the community stressor. Individuals’ personal stories may be motivating or inspiring to others, but it is important that they understand the ramifications of their participation. Personal stories “put a face” on a social problem, but they also can increase individuals’ vulnerability and distress, open them up to unwarranted scrutiny, or both. In the previous example of the parents who banded together to advocate for a neighborhood substance abuse treatment program, one couple lost their

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son to a drug overdose. These parents’ painful experiences were highly motivating to others, and their impassioned pleas to local public health officials were critical to the effectiveness of the change strategy. They made a conscious decision to reveal their loss, with the understanding that as they engaged in collective action with their neighbors, their grief might intensify and require the assistance of others. A social worker also might reach out to local churches, synagogues, mosques, and other institutions held in high regard within the community. In addition to recruiting influential members of a community, the worker should take into consideration whether a diverse constituency is required for successful action. The social worker may need to purposely recruit members who represent diverse formal and informal community systems and perspectives; the broader the representation, the greater the chance for legitimacy and influence. In some cases, representatives of the intended targets of a community’s change efforts might be strategically asked to become participants in the change efforts. In the earlier example of a health clinic’s efforts to tackle rat infestation, once staff had collected sufficient information about the scope and source of the problem, they asked city officials from the sanitation department and code enforcement (the department tasked with ensuring that rental properties are compliant with local zoning laws) to attend a community meeting. This meeting included the clinic’s patients and other community residents. This provided an opportunity for residents to air their complaints directly to those individuals who had the power to address them. In other cases, the social worker may intentionally recruit individuals with opposing viewpoints and attempt to engage them in a collective effort. In the example of the community effort to locate a substance abuse program for adolescents in the neighborhood, there was some opposition to this proposal. To address this potential barrier, the worker held a community meeting and invited parents and others who supported the idea of a neighborhood drug treatment program and residents who did not. This allowed individuals on both sides of the issue to see one another’s perspective. The benefit of diverse perspectives is evident in the previous example of the methadone maintenance clinic’s initiative. The clinic sponsored a number of meetings at its facility and at various locations in the community. There, the clinic staff took the opportunity to explain the nature and benefits of methadone maintenance programs, and participants were invited to air their questions and concerns. Two national organizations, the National Alliance of Methadone Advocates (NAMA) and Advocates for Recovery through Medicine (ARM), provided written materials and handouts. Presenters included addiction specialists,

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including the social worker and her colleagues, employers who hired the clinic’s patients, and patients, themselves. Staff specifically reached out to community members and representatives who expressed or were assumed to have reservations about the program and its patients. At the close of each meeting, attendees completed a brief survey to determine whether their views of methadone maintenance had changed. Six community meetings were held over a four-month period, and survey responses suggested that acquiring accurate information about methadone maintenance did alter attendees’ views. During this same time frame and continuing beyond it, clinic staff continued to ask clients whether they experienced any change in how they were viewed in the community. Many clients reported that they felt less stigmatized and more accepted; another indication of the success of the community outreach was an increase in the number of clients seeking treatment from the clinic. Enhance motivation. In chapter 2, we discussed the linked concepts of psychological and social impotence. Marginalized and disadvantaged populations experience significant barriers to obtaining needed resources and participating fully in social life. Social impotence is a source of much stress. It also leaves individuals with feelings of powerlessness and despair reflected in the question, “Why bother? Nothing I do will make a difference.” This psychological impotence is an understandable and inevitable reaction when individuals have restricted opportunities and limited access to resources. Therefore, a significant challenge when social workers engage community members in social change efforts is motivating them and helping them see that change is possible (Hoefer & Chigbu, 2015). Using the stages of change model as a guide, we can assume that in many instances, community members recognize that there is a problem (and often there are multiple problems); they are in the determination phase. However, in response to the question that accompanies this phase (“There’s a problem, now what do I do?”), the answer often is, “Nothing, because nothing will ever change.” Therefore, an important early task in mobilizing residents is helping them see that change is possible through their collective efforts. This means helping members move from determination to action. Help community members develop critical consciousness. Enhancing community members’ motivation to engage in collective action often requires workers to engage in critical consciousness-raising activities that help them adopt a transactional view of the stressors they face (Hays, Arredondo, Gladding, & Toporek, 2010). The social worker helps community members see the role that broader social forces play in creating and maintaining the stress in

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their lives, as well as the role they can play in resolving the issues (Christens & Speer, 2011; 2015). Community members become aware of how collective action can address the stressors they face, consistent with locality development, and/or how their collective efforts can effect broader social change, consistent with social action. The experience of two social work students placed in public schools illustrates the importance of these activities: Alana was placed in a city elementary school located in a neighborhood known for drug activity and violence. Many children had lost loved ones to addiction and violence, while many others demonstrated signs of posttraumatic stress disorder (PTSD). The teachers and the principal and vice principal frequently expressed concerns for their and their students’ well-being and safety. There was much discussion but little action, since school personnel believed that there was nothing they could do. The turning point came when a gunfight erupted on the school’s playground. Although no children were on the playground at the time, most heard, and some saw, the fight, which resulted in serious injuries to several individuals.

The field instructor, Judith, and Alana approached the principal and suggested that she call a meeting for all school staff to discuss what they could do to keep themselves and their students safe. Although the principal expressed skepticism that she or her staff could do anything, she agreed to call the meeting. Prior to the meeting, the social workers visited each classroom, informally chatting with teachers and staff in the faculty/staff room and urging them to attend the meeting. Staff was included in the meeting because many of them lived in the neighborhood and were essential members of the school team. Alana and Judith engaged in anticipatory empathy in an attempt to understand staff members’ reluctance to get involved, since both acknowledged being frustrated and angered by the school staff ’s “disinterest” and unwillingness to take action. This allowed them to appreciate that these reactions most likely reflected staff members’ belief that the neighborhood violence was too overwhelming and intractable for them to do anything about it, not a lack of caring for their students. After the principal called the meeting to order, she turned it over to the social workers. Judith opened the discussion by saying the following: We’re so glad you agreed to attend this meeting today. We’ve talked with many of you, and you’ve said how worried you are about your students and what they’re exposed to. And we’re all concerned about our own safety. Also, many of you live

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close by, so you deal with this every day. I know it feels like the violence in this neighborhood is too huge and too chronic for us to do anything about. But we think there are things we all can do to make the school and the neighborhood safer for everyone. But let’s start with what your concerns are both about the problems in the neighborhood and what you all want to do about them.

In another similar situation, a social work student, James, and his field instructor, Tanya, organized a meeting of parents of children in an inner-city elementary school to address the problem of the school’s unsafe playground.1 Once James and Tanya welcomed the 12 parents and guardians who attended the meeting and the participants described their concerns about the playground’s safety, angry arguments erupted. The exchanges revealed long-standing conflicts regarding drug dealing in the neighborhood, loud music, out-of-control youths, and discarded trash and debris. Two members of the community in particular were singled out and portrayed as the primary cause of the neighborhood’s problems. Using the group work skills of acknowledging members’ anger and pointing out underlying commonalities, Tanya acknowledged the anger but then went on to say: You all live in very tough circumstances. You want to make your homes and your neighborhood safe for yourselves and your children, but it’s an uphill battle. It’s easy to blame one another. But the reality is that the city has abandoned you. Think about why you are here . . . the unsafe nature of the playground. Your children have a right to a safe space to play. If the City isn’t going to do anything about it, then maybe it’s up to us all to work together to make things better. We’re hoping that you can put your differences aside to tackle something you all care about.

In both of these illustrations, the social workers needed to help community members develop a universal perspective (Shulman, 2012), whereby they can appreciate the ways in which they have been affected by broader social forces. Readers should note that in the first example, the workers’ initial efforts are directed toward mobilizing school personnel. While not necessarily members of a marginalized group, they still experienced psychological impotence that kept them from taking any action to confront the neighborhood violence. Mobilizing school staff was an important first step toward involving community residents in efforts to make the playground and their neighborhood safe. The need for enhancing a community’s critical consciousness is particularly evident in the second example. Rather than see the common source of their stress, the parents turned their anger toward one another. The social worker’s

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observation that parents were “all in the same boat” due to the city’s negligence encouraged them to turn their anger outward, which fostered the motivation needed for them to engage in collective action. These examples illustrate the importance of group work practice skills that assist members in seeing their common challenges. These connecting and differentiating skills include the following: 1. 2. 3. 4. 5. 6. 7. 8.

Scanning Directing members to talk to one another Assisting members in managing intense feelings Reaching for differences Inviting members to participate and build upon one another’s communications Putting members’ reactions to one another into words Connecting the individual to the group and the group to the individual Identifying common themes

The worker uses these skills to help community members resolve disagreements that prevent them from working together collectively. The worker’s efforts in this regard also model how community members can handle internal disagreements when they occur in the future. Helping Members Develop a Stake in the Work

The practitioner’s initial contact and recruitment efforts often determine whether community members decide to become involved and the extent of their involvement. The social worker must give careful consideration and preparation to what will be said to potential recruits, as well as their possible reactions. Using skills associated with anticipatory empathy, the social worker must anticipate, invite, and explore initial distrust, fear, reluctance, and ambivalence and address possible questions like, “What’s in it for me if I join?” “What do I have to contribute?” and “How can anything we do make a difference?” (Mondros & Wilson, 1991, p. 50). Social workers also use skills associated with clarifying their role and purpose. The statement should be clear, direct, and responsive to the interests and motivations of potential members. Consistent with how we explain our role and purpose in social work practice with groups, we must convey to community members that we are there to help them to help each other to engage in collective action that improves their mutual well-being.

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In the first meeting, the social worker identifies a common focus and interests and explores fears, doubts, and hesitations. The worker must avoid slipping into “selling” rather than inviting, exploring, and developing a mutual focus. In the two examples presented previously in our discussion of developing critical consciousness, the social workers did not dictate to potential recruits to their community practice initiatives what the problem was or how to resolve it. Instead, they encouraged participants in the initial meeting to share their perspectives and helped them see their common sources of stress and the potential for change that collective action represented. Successful recruitment and effective description of purpose and the professional role generate initial interest in dealing with a community issue. Offering refreshments, attending social meetings or events to become acquainted with community members, and using icebreakers at meetings encourage active participation and help participants to feel more at ease with one another. Helping Members Create a Structure for Work

As members begin to invest themselves in collective action, the worker needs to help them develop a structure for work. Whether members’ work together will be time-limited and focused on one particular objective or ongoing, they are likely to require the worker’s assistance in creating a leadership structure that allows them to do their work. A structure that fosters inclusiveness and provides all members with an opportunity to have a voice also enhances their commitment and motivation to engage in collective action (Cheezum et al., 2013; Collura & Christens, 2015). For community members to engage in sustained collective action, they must be involved in developing guidelines regarding their participation. The guidelines that we establish in cooperation with community members should help them work together in productive and effective ways. With the worker’s assistance, a community group may need to identify individuals who can serve in leadership capacities. In larger groups, this may include electing a president, vice president, and other similar positions. In smaller groups, individuals may be identified or volunteer to serve in leadership capacities. Because formal group roles and a leadership structure are likely to be new to community residents, the social worker initially may need to be active in guiding structured participation and decision-making processes. The parents group organized to bring a drug treatment program to their neighborhood engaged in a focused endeavor that began and ended— successfully—with the city opening a treatment program for adolescents that

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was convenient for the neighborhood. Once a core group of members was established, the worker assisted them in identifying individuals who would lead their collective efforts. The parents whose son died due to an overdose became outspoken advocates and the “face” of the community’s efforts. Another individual, who was a long-term and highly regarded resident of the community, and whose children were grown and had moved away, agreed to organize and advertise community meetings. Yet another neighbor, a parent of two children in the local high school, assumed the role of the leader at meetings; and another took on the role of secretary, making and distributing summaries of each meeting. These five individuals led the change efforts and the parent group’s interactions with the city, but all members of the group (and others who supported the action but may not have attended the meetings) were encouraged to participate. In some cases, a community’s response to one particular problem may lead to a more sustained effort to improve community life, consistent with locality development. Consider the actions that Tanya, James, and the community took following their initial meeting about playground safety: 1. The social workers asked attendees at the initial meeting to identify individuals to include in their efforts to clean up and maintain the playground. Parents mentioned the pastors of two churches in the community, the owner of a gym that catered to young men in the neighborhood, and Ms. Esther, a highly respected elderly resident who had lived in the community for over 50 years. 2. The social workers contacted each of these individuals, as well as several others that were recommended (including the lay pastor at one of the churches, the owner of a local funeral home, and a young resident of the neighborhood who was a DJ) and invited them to attend the next community meeting. Additional attendees at the follow-up meeting included participants from the original meeting and friends, relatives, and neighbors they recruited. 3. With the workers’ assistance, attendees gradually coalesced to form a working group whose initial focus was the unsafe playground. Over time, the community group’s purpose expanded to become a neighborhood watch group that monitored not only the playground, but also the general appearance of the neighborhood. The watch group also coordinated and sponsored periodic block parties that encouraged neighbors to get to know and socialize with one another. 4. From the beginning, certain individuals emerged as leaders and assumed responsibilities that reflected their particular strengths and position within the community. One parent who attended the first meeting was well liked by fellow parents and other residents and assumed the role of president of the neighborhood watch

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group. A relative of the funeral home owner, whose child also attended the elementary school, assisted her. 5. For the initial cleanup effort, the owner of the gym recruited young men who trained at his facility to clean up the playground and the surrounding neighborhood. Ms. Esther and her friends provided baked goods for the cleanup efforts, and the DJ helped organize the first block party.

In another example, a social worker working with one family living in public, high-rise housing discovered that many families experienced severe interpersonal stress generated by conflicts that occurred in the public stairwells and shared hallways. The social worker hypothesized that if positive change began in the public areas, this could lead to positive change in the building, and ultimately in the total public housing community. She initially organized meetings according to the stairwell that residents used. This provided families with an opportunity to deal with their disagreements and to elicit their shared concerns about their social and physical environments. Consistent with the need to help community members engage in critical consciousness-raising, residents were encouraged to identify their common stressors and environmental needs and plan for and take action to achieve goals such as improving maintenance, developing recreational facilities, improving relations with the school, and the like. These stairwell meetings laid the base for what became a tenants’ association that would go on to address shared life issues of the total public housing community. Association members approached the housing authority about required improvements with confidence and competence. Community members will often need a social worker’s guidance and consultation in learning to conduct their own meetings, engage in democratic group decision-making, reach out and build constituencies, deal with differences, and build a consensus. Conflict management is an indispensable skill in forming groups and developing and sustaining mutual support. Conflict is neither bad nor good in itself. The social worker’s responsibility is to help members develop strategies to successfully resolve it. The social worker must expect that in most community groups, differences in perceptions and opinions, competition for power among natural leaders, and testing whether the worker’s willingness to share power is genuine are likely to emerge. Members may tend to avoid or control their differences. When differences and conflicts are suppressed, positions harden, and the conflicts persist or are driven underground, only to reappear later and drain the group’s energy. Premature consensus should be challenged and differences and conflicts welcomed and invited.

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As in any mutual aid group, problematic dynamics may surface, such as monopolization, scapegoating, and collective avoidance. In these instances, the worker may need to use the mediating skills presented in chapter 11 to help community members address these internal processes that block their ability to work together. In the parents group formed to bring a drug treatment program to the neighborhood, tensions arose early in their collective efforts, as one member dominated the discussion and, as a result, began to be scapegoated. Mr. Steadman not only monopolized discussions, but frequently provided suggestions that seemed to “come out of left field.” The worker quickly realized that she had to intervene if the members were going to be able to work collectively to engage in community change. After one particularly heated exchange in which Mr. Steadman’s suggestions were met with derision and laughter, the worker observed: Hold up folks; let’s take a few minutes to talk about what just happened here. Mr. Steadman offers a lot of advice about what he thinks needs to be done to get this treatment program, but it seems like you don’t like his ideas? I’m thinking that perhaps Mr. Steadman just wants to see something done, and done now. He’s throwing out all sorts of ideas since he’s told us how worried he is about his grandson [whom he is raising] and his drug use. (to Mr. Steadman) Everyone knows how much you want to get something done. I think that’s what everyone wants. (to the group) How about if I help you all come up with strategies that you can use to get the city to listen to your concerns? (turning to another member) Ms. Elliott, I know you’ve been trying to jump into the discussion; how about we start with you?

The worker’s comments reframed Mr. Steadman’s behaviors in a way that connected him to the group and helped them see that his actions reflected his heightened sense of urgency. He was raising his grandson because his daughter—his grandson’s mother—had died of a drug overdose, and he had recently discovered that his grandson had begun using drugs. Because his suggestions were somewhat unrealistic (he wanted the group to contact the state’s governor and hold a sit-in at the mayor’s residence and at the adultonly drug treatment program), it also was important for the worker to help him listen to and work with others. As we discuss next, change strategies must be, as this worker said, doable as well as likely to succeed. Table 14.2 summarizes the practice skills associated mobilizing community members to take collective action.

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Table 14.2 Professional Tasks and Skills for Helping Community Members Engage in Collective Action Assess community needs and strengths.

• Top down: Community needs first identified by others. • Bottom up approach: Community needs identified by members themselves • Hang out in the community. • Talk to key community leaders. • Conduct formal surveys.

Mobilize members.

• Tap into natural networks. • Recruit representatives of diverse constituencies. • Identify and recruit influential members.

Enhance motivation.

• Anticipatory preparation. • Convey hope. • Help members move from determination to action stage. • Help members develop critical consciousness.

Help members develop a stake in the work.

• Engage in anticipatory empathy. • Clarify the worker’s role and purpose. • Invite and explore reactions, doubts, ambivalence, and fears. • Help members develop a shared focus.

Help members develop a structure for the work.

• Develop a leadership structure that promotes inclusiveness. • Develop guidelines for how members will work together.

Help members sustain • Challenge premature consensus. collective action over time. • Welcoming and inviting differences and conflicts. • Model comfort with differences. • Convey faith in the democratic process. • Address maladaptive processes.

Identifying and Implementing Change Strategies

Community members are unlikely to appreciate how their collective actions can improve community and neighborhood life. Therefore, they will need our help in deciding upon a strategy. Like Mr. Steadman, community members may want

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to engage in conflict strategies immediately. However, these approaches often should be the last resort, not the first initiatives that members undertake (Rothman, 1996). A building superintendent referred Mrs. Rosen, a 69-year-old, mentally and physically frail woman living in a small apartment in a poor, crime-ridden community, to a community-based social agency because of her erratic behavior. Micaela, a social work student providing direct services to clients, was assigned to work with her. The city’s public housing authority ran the building, which housed 40 elderly people. Mrs. Rosen complained to Micaela of feeling friendless and fearful because the emergency alarm system, intercom, and front door buzzer had been broken for almost a year, and the housing authority had not responded despite the high crime rate in the neighborhood. During her weekly visits to Mrs. Rosen’s apartment, Micaela observed that the tenants came together only while they waited in the lobby for mail delivery, with little or no social interaction. While continuing to help Mrs. Rosen with her individual life stressors, the social work intern also involved herself in the larger issues facing the community of elderly residents. For several weeks, she made a point of introducing herself to those in the lobby, and many told her of experiencing loneliness and fears similar to those of Mrs. Rosen. Some expressed a wish for social activities in the building’s lounge, which is hardly ever used. Most despaired of ever having their requests met by the housing authority. Micaela came to view the residents as a congregate whose members had common needs and concerns. Her brief initial assessment of the building as a community included the following points: 1. Strengths. The superintendent, who is also frustrated with the housing authority’s red tape, is a potential ally. One resident is a natural helper, who has hosted holiday parties for the other residents, is active in community affairs, and knowledgeable about resources. 2. Obstacles. The obstacles include an unresponsive bureaucracy, physical and cognitive impairment of many of the elderly tenants, and the lack of a cohesive, organized group structure.

Micaela inquired into residents’ interest in meeting together. Some were interested in social gatherings, others desired informational meetings, and several thought that they should work together to influence the housing authority. Next, the worker canvassed the group for volunteers to plan the first meeting. Several tenants prepared announcements of meeting dates and topics. In the first two meetings, snacks and refreshments were provided by Micaela’s agency.

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After tenants had the opportunity to socialize with one another, they shared information gathered by several tenants on comparative drug prices in neighborhood pharmacies, and an outside speaker discussed elder health. The group decided next to hold a planning session to discuss needed repairs. The meeting was attended by 12 residents. Plans were worked out, an agenda developed, and individual presentations to the housing authority rehearsed. Micaela helped residents compile a detailed list of the repairs that were needed, as well as the negative consequences they had experienced. An invitation to attend another meeting was sent by the planning group to the authority’s director, and that meeting drew 30 residents. The director was unable to attend, but he sent three representatives. The agenda was followed, and the residents’ presentations were clearly and firmly stated. The group then formally requested that the needed repairs be started within two weeks. The three representatives, on the other hand, stated that they would need a few months to initiate the repairs. Members were prepared to negotiate, and eventually all the participants settled on a six-week period. The members scheduled a follow-up session with the representatives in two months to evaluate the results of their efforts and to plan next steps. The repairs actually began before the end of the month. At the end of her placement, the student concluded: The educational programs and social activities the tenants requested facilitated their active engagement with one another. This, in turn, led to increased social skills, enhanced confidence and self-esteem, and the beginning of a social network. This was possible because of residents’ growing interest in organizing themselves as a cohesive group to do something about the serious problems in their shared physical and social environment.

This vignette reveals what can happen when a practitioner helps community residents achieve their desired goals. The student’s personal contacts with the elderly residents engaged their interest and resulted in active participation. In this situation, only mild confrontation was sufficient to achieve housing repairs. These impoverished elderly residents also developed a new sense of themselves as a social congregate within their surrounding neighborhood. They became more self-directed, with an increased sense of competence in dealing with common life issues generated by their shared environment, an increased sense of collective empowerment, enhanced self-esteem, and beginning to feel a relatedness to one another. In this case, the residents’ action plan relied upon organizing themselves, developing a detailed description of repairs and a rationale for why they were

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needed, identifying individuals who had the power to respond to their complaints, and creating a division of labor of who was going to do what. The residents’ compelling presentation was enough to convince representatives of the housing authority to make the needed changes. Therefore, more confrontational, conflict-oriented strategies were unnecessary. In fact, it is likely that had residents employed such strategies first, they might have alienated the very individuals from whom they needed assistance. As with any client group, Micaela helped residents consider options that they might have needed to use if their demands were not met. Our clients can never be sure that their efforts will bring about the desired results. Therefore, we have a responsibility to help them be realistic and to anticipate what could happen, in addition to what they want to happen. If the residents did not meet with success through their meeting with housing representatives, Micaela helped them identify their next steps. In the discussion that follows, we identify these possibilities. The Use of Consensus or Conflict Strategies

The example of the elderly housing group reveals the use of a consensus strategy to effect community change. The targets of the residents’ efforts were amenable and responsive to their concerns and demands. Consensus strategies also often are effective when the goal of community action is locality development. In other cases, particularly when targets of the community’s efforts are unresponsive or when consensus strategies have not been successful, more conflict-oriented strategies will be needed (Force-Emery Mackie & Leibowitz, 2013; Rothman, 2007; Thomas et al., 2011). These strategies exist on a continuum from those that involve little to no conflict at one end to high conflict on the other. The selection of an appropriate approach depends upon factors such as the community’s goals, the anticipated degree of resistance, and the community’s level of participation. A discussion of these strategies follows. Bargaining. Micaela’s work with elderly residents employed a low-conflict bargaining strategy: the members demanded that repairs to their apartments start within two weeks. Initially, the housing authority representatives stated they would be unable to start work for several months. After some back-andforth, all agreed upon a six-week time frame within which the repairs would be done. An effective bargaining strategy often begins with a demand that reflects community members’ most desired outcome. Using this as the starting point, members and targets have room to maneuver and ideally arrive at a solution that still meets the community’s demands and needs.

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Negotiating. This strategy usually requires a community to be more assertive, as was evident in parents’ efforts to bring a drug treatment program into their neighborhood in the example earlier in this chapter. The director for public health in the city, as well as the director for substance abuse services, attended a community meeting at which designated community members conveyed their concerns and requests. The speakers included the parents of the young man who had died of an overdose; the school principal, who attested to the rampant drug problems among students at the school; and other community residents. Community members had decided that they would demand that the neighborhood drug treatment program open its services to teens and provide the same level and duration of care currently provided to adults. While the public health representatives conceded the legitimacy of the community’s concerns, they maintained that the clinic did not have the resources to expand its client base and argued that the city did provide sufficient services to adolescents at other locations. Accessing these services required the teens to travel to clinics outside their neighborhood. Over a three-month period, the following events occurred: 1. There was an ongoing dialogue between the community and the public health department, in which the community continued to demand more conveniently located services and the department continued to maintain that this was not possible for financial reasons. 2. During this same period, community residents and school personnel, including the social worker, collected additional information that documented the extent of the problem and the cost of transportation for teens to travel to the clinics available to them. 3. The social worker also met with staff employed by the neighborhood clinic and obtained their feedback on the feasibility of expanding the clinic’s services, assuring them that she would not use their names and would only report a summary of the comments they had shared. 4. Coincidentally, two teens—both students from the high school—overdosed during this period (fortunately, they recovered). With the social worker’s guidance, and at the consent of the teens’ families, the community contacted local television and radio stations about the recent overdoses and their struggle to provide teens with accessible drug treatment. 5. At a subsequent meeting with public health personnel (which also was attended by two local television stations), the community presented the additional information that it had collected to the officials and reiterated their demand for the local clinic to expand its services. One critical piece of information that members

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conveyed to the city officials was that the cost of expanding services to individual teens was far less than the cost associated with drug overdoses. The discussion became heated, with members asking out loud, “How many more of our children have to die before you do something?!” 6. The officials continued to maintain that there was nothing they could do because it was a problem of resources, but they agreed to discuss options with other public health personnel and city officials. 7. After yet more back-and-forth, the city agreed to expand the local clinic’s services to include teens. However, services to teens were limited to 10 sessions (whereas no such restrictions were placed upon adult clients), reflecting financial considerations. 8. Further discussion with city personnel resulted in the neighborhood clinic providing tokens so that teens and their families could take public transportation at no cost to other public health agencies to continue their treatment.

The community’s efforts did not produce the ideal outcome, but it did lead to the city acquiescing in some significant ways to its demands. The city’s willingness to take these actions reflected the community’s persistence and its ability to use a negotiating strategy effectively, diligence in collecting information that was persuasive, and strategic use of the media. While unforeseen and certainly not desirable, the teens’ overdose also provided a powerful incentive for members to continue their efforts and for the city to be responsive to their demands. Taking coordinated public action. Community members are directly involved in this strategy, requiring them to become more assertive. These can range from sit-ins, boycotts, protests, and demonstrations. In some instances, the activity may involve community members simply showing up to make a point and convey their collective concern about a particular issue. This optic can be persuasive to lawmakers, representatives of targeted institutions, and the general public. The following example illustrates this strategy. During one state’s legislative session, a bill was introduced that would provide additional financial resources to local jurisdictions to increase funding for shelters for homeless individuals. The bill had been sponsored by a coalition of shelters, other social service and health agencies, and church and civic leaders. The day when the bill was to be heard in the state legislature, shelters from throughout the state arranged for a large contingent of their staff and clients to travel to the state’s capitol to hold a rally in support of the bill. The organizers believed that the presence of large numbers of homeless individuals—particularly women, children, and families—humanized the problem. The organizers

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invited local media, and news coverage that evening showed what appeared to be hundreds of individuals surrounding the state house. Organizers of the event were interviewed on camera, as were several homeless individuals who had been selected and prepared to speak by shelter staff. Despite this coordinated effort, the bill did not make it out of committee. Lawmakers acknowledged the need for more funding for shelters but stated that they were unable to find funds to do this, citing competing priorities. This endeavor illustrates six considerations associated with organizing a public effort: 1. Mobilizing large numbers of individuals to advocate for (or against) a particular issue is visually compelling and may serve as a powerful force for change. 2. Putting a “human face” on a social problem may be persuasive to decision-makers. 3. Not all “human faces” are equally persuasive. The organizers recognized that homeless women and children were likely to elicit more support and concern from lawmakers than homeless men, who stereotypically were seen as responsible for their status. 4. The participation of professionals in social action efforts lends legitimacy and may be needed to bring attention to a particular social problem. 5. Generating media attention can be helpful in putting a spotlight on a particular social problem and putting pressure on decision makers. 6. Adopting a social policy approach in addition to social action often enhances the community’s chances of success. A range of professionals involved in the care of homeless individuals provided data on the causes, extent, and consequences of the problem.

While the organizers presented data in support of the legislation, they had neglected to engage in a cost-benefit analysis. In addition to providing detailed information about the scope of a social problem, social workers often need to provide information that can demonstrate that the costs associated with a desired social change are offset by benefits in the form of savings in public dollars, improved public health, and the like. The organizers had not considered the reality that their request for additional funding had to be considered within the larger context of the state’s funding priorities. The organizers might have achieved some success if they could have demonstrated how increased funding for homeless shelters would save public tax dollars through, for example, reducing hospitalizations for and arrests of the homeless, which are paid for by public monies. Another benefit might have been the potential for increased income to jurisdictions that would result

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from more individuals being willing to travel to and spend their money in areas where homeless people had previously congregated. Decision-makers rarely are persuaded to support a community’s cause because it is the right thing to do. That is why cost-benefit analysis can be such a critical aspect of information gathering. Unfortunately, it often is quite difficult to quantify the benefits of a particular community initiative. The goals of community practice often are costly and may not be offset by benefits (at least financial ones). The uphill battle that communities face in advocating for their interests may demand that more conflict-oriented strategies be employed—or threatened—like boycotts, sit-ins, protests, and demonstrations. Saul Alinsky, one of the earliest and most influential community organizers in the field of social work, assumed that conflict was inevitable as disadvantaged and marginalized communities engaged in collective action to gain and wield more power (Alinsky, 1969; 1971). Underlying this assumption was his belief that power was a finite commodity—those who have it want to hold on to it, and those do not have it, want it. Conflict strategies aim to deal with these power differences. Community residents often find themselves in conflict with institutional power structures, since their collective action poses a threat to the status quo. When communities engage in boycotts, members collectively agree to avoid using, buying from, or interacting with a targeted institution and its representatives. A boycott can put economic pressure on the targeted institution, forcing it to negotiate with or concede to community demands. Sit-ins create disruptions in the routine functioning of an institution as community members occupy its offices, lobbies, and public spaces. The inconvenience and publicity associated with a sit-in may lead the targeted institution and its representatives to acquiesce to the community’s demands. In a protest or demonstration, members publicly—and often loudly—convey their support for or opposition against a particular social problem, public initiative, piece of legislation, and the like. This type of collective action often involves carrying signs, marching in unison, chanting slogans, and having public speakers who rally support for the cause and convey participants’ demands. Each of these efforts requires sustained and widespread collective action to be effective. We have noted how important—and difficult—it is for the social worker to motivate community members to engage in any sort of collective action. It often is even more challenging to help communities sustain their collective efforts over time (Christens & Speer, 2011). Boredom, frustration, and the need to attend to issues that surface in their everyday lives all serve to undermine the members’ prolonged commitment to collective action. For this reason, community practice

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Table 14.3 Considerations Associated with Collective Change Strategies Consensus strategies

• Often effective in locality development • Target amenable to the community’s demands/requests • Bargaining • Negotiating • Often the strategy of first resort

Conflict-oriented strategies

• Target unresponsive to the community’s demands/requests • Maximize pressure through boycotts, sit-ins, and/or demonstrations • Utilize media • Identify community members who can be the “face” of the social problem • Utilize professionals and experts to legitimize the problem

Cost-benefit analysis Ethical considerations

• Whatever strategy is adopted, identify how the benefits of a proposed change outweigh the costs • Informed consent • Minimize risks to clients

often is limited in scope and focused on small incremental changes (Foster-Fishman, Fitzgerald, Brandell, Nowell, Chavis, & Van Egeren, 2006). This is particularly likely to be the case when our primary responsibility is to provide direct services to clients. Like community members, we may have neither the time nor the energy to maintain long-term involvement in community practice. This underscores the importance of us helping a community to develop its own leadership structure. In the final case example that follows, we describe the realities of and challenges associated with using conflict strategies like protests as a community practice strategy. Table 14.3 summarizes the considerations associated with the selection of change strategies. Case Example

In April 2015, in Baltimore, Maryland, a large urban city, police picked up a young black man, Freddie Gray, off the street. While this young man had previous involvement with the criminal justice system, it was unclear what led to police taking him into custody. While he was being transported to the local precinct, Gray suffered serious injuries that ultimately led to his death. His death

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sparked rioting, looting, and the torching of local businesses and residences as the local community erupted in rage at what was seen as yet another case of police brutality against a young black man. Six officers were charged in connection with his death, but none was convicted. This young man’s death and the riots led to numerous efforts to tackle the underlying problems that plagued this community and the city in general. Gray lived in a neighborhood that had disproportionately high rates of poverty, poor health, juvenile arrests, and murder, and the highest rate of adult and juvenile incarceration of any jurisdiction in the state (Knight, 2017a). Some of these efforts represented grassroots efforts; neighborhood residents took it upon themselves to address the problems of drugs, violence, and police brutality plaguing their communities. Public institutions, like the city’s health department, initiated other efforts. Still other efforts were undertaken by private agencies whose clients were affected by and lived in the young man’s neighborhood and in other communities throughout the city. Several students from the institution of one of the coauthors were placed in these agencies. Gray’s death and the riots occurred in April, close to the end of students’ internships. Two students, placed at the same agency, began to work with their field instructor to develop a community initiative designed to reduce the violence in the neighborhood. During the next academic year, another student was placed in the agency and picked up the work begun by the previous year’s students. The agency was an outpatient clinic that provided comprehensive mental health services to community residents. Prior to the riots, clinic staff already had been seeing numerous clients experiencing symptoms associated with stress and anxiety; following Gray’s death and the riots, staff observed a significant uptick in the number of clients seeking services and in symptoms associated with PTSD. This prompted the social workers to propose that their agency more aggressively reach out to the community and help them organize an effort to demand that the city address the violence, their concerns about police brutality, and law enforcement’s indifference to the crime and drug activity in their community. The workers’ initial efforts reflected strategies that we have previously identified; they included the following: 1. Organizing community meetings to discuss residents’ concerns 2. Collecting detailed information about clients being seen at the clinic, including the reasons for their visits and presenting problems 3. Collecting anecdotal data from attendees at the community meetings about their encounters with violence

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4. Going door to door to recruit residents to attend meetings and provide additional information about the neighborhood’s ills 5. Using publicly available data to document the level of violence and drug activity in the community 6. Working with residents to develop a strategy to persuade public officials to address their concerns

Gray’s death and the riots led to a high level of motivation on the part of the community to confront public officials. Their anger and sense of injustice were powerful incentives for members to work together. The community meetings were well attended. Residents readily offered their ideas and volunteered their time, and they quickly coalesced into a community group intent on social action. Because previous efforts on the part of the community to appeal to public officials and law enforcement (which predated Gray’s death and the riots) had been unsuccessful, the social workers and community residents decided that the following conflict strategies were necessary: 1. A rally and protest were held at city hall, attended by a large contingent of community residents; medical, education, and social service professionals; and lawmakers who represented the district. 2. The rally drew a large media presence and hence was widely covered in the news. 3. Many protesters carried signs and wore clothing that identified loved ones whom they had lost to violence or drug overdoses. 4. The protesters demanded a meeting with the mayor and other top city officials. 5. A representative from the mayor’s office acknowledged the protesters’ concerns and indicated a willingness to meet.

After weeks in which there had been no response from city officials—despite the fact that protests organized by other groups continued to occur—the social workers once again organized a series of community meetings. At this point—five months after the riots, when the new social work student was in the placement— the workers had a difficult time generating interest among residents, despite the fact that they once again went door to door and posted signs throughout the neighborhood. Several meetings were held, with a much smaller contingent of residents expressing interest in continuing to pursue their complaints with the city: 1. Initially, the residents, the social workers, and other clinic staff decided to initiate an e-mail and telephone call campaign to select city representatives to request a meeting to discuss the community’s concerns about the continued violence.

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2. Community members once again contacted the media to express their anger that their demands were being ignored. 3. The outreach to the city and the media was unsuccessful, so another protest rally was planned at city hall. 4. This rally drew far fewer attendees than the previous one. Those in attendance passionately conveyed their anger, and in many cases their grief, at the loss of their loved ones and neighbors to the violence. 5. The media attended and covered the event. 6. A representative of the city made an appearance at the protest and acknowledged the residents’ concerns, assured attendees that they were working on the problem, and promised that city personnel would visit the community to continue the discussion.

However, the meeting with the city representatives never occurred, despite residents’ continued efforts to make this happen. However, two initiatives resulted from Gray’s death and the riots. One was a publicly funded program, Safe Streets, which placed previously incarcerated individuals in communities to resolve disputes before they led to violence. Another grassroots effort, City Ceasefire, involved community activists and volunteers advocating for and organizing weekends with no murders. Despite these and other initiatives, the city’s murder rate continued to be at unprecedented levels. Freddie Gray’s death and the subsequent riots revealed the chronic social problems that existed in his community and many others in the city. Initially, these events generated much anger and a strong desire among community residents to finally do something. From the outset, city officials acknowledged the problems and vowed to address the violence that plagued many city neighborhoods. However, despite the efforts of many groups, including the one mounted by the social work students’ agency, little changed. Practical Challenges Associated with Community Practice

As this example reveals, communities and social workers engaged in community practice face an uphill battle due to the chronic and multidimensional nature of the social problems that plague marginalized communities. Sustained, multipronged, and coordinated action is needed to tackle the numerous social ills that these communities face due to poor educational systems; chronic unemployment; high rates of incarceration, gang activity, and drug abuse; and limited job opportunities. While Freddie Gray’s death sparked outrage that spurred residents and professionals to action, their motivation and commitment to continue their

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efforts diminished over time as their demands went unanswered. We believe that many public officials in this city were—and remain—sincere in their desire to improve conditions for the most vulnerable residents. However, such improvements require a great deal of time, effort, and research to identify effective solutions. This requires money and the general public’s commitment to eliminate the ills that plague these communities. While significant social problems continue to plague this city’s vulnerable neighborhoods, community and professional activism also continues. It is our belief that positive changes will occur and are occurring in small ways. When the social problems such as those that plague the city’s neighborhoods are so deeply entrenched, their resolution will take years and continued persistence on the part of both those demanding change and those who have the power to create it. Readers will no doubt recognize the parallels between Gray’s death in 2015 and the riots and social unrest that ensued and the murder of George Floyd in 2020 and the massive, worldwide Black Lives Matter protests that followed. As this textbook goes into production, protesters from all walks of life continue to demand racial, social, and economic justice and police reform. While it is clearly premature to predict the outcome of these efforts, the authors hope that the time may have come for real, lasting, and systemic change that dismantles or greatly diminishes the white, social privilege enjoyed by some at the expense of so many others. As of this writing, state and local legislatures are taking up efforts to reform law enforcement in their communities and debating the removal of Confederate statues and other symbols associated with white privilege. Congress also is debating police reform and may be poised to address broader issues associated with income and social inequality that the COVID19 pandemic has revealed. Only time will tell whether these initiatives come to fruition and lead to the more far-reaching social justice reforms to which our profession is committed. Ethical Challenges Associated with Community Practice

A previous example in this chapter, involving organizing the homeless, reflects some of the ethical challenges associated with community practice. The organizers for the homeless rally at the state capitol had great difficulty mobilizing their clients to participate in the rally, even though they provided transportation and lunch. This reflected these individuals’ sense of hopelessness and despair— what we have referred to as psychological impotence—as well as their physical and mental health problems.

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To inspire participation, several agencies decided that they would withhold their clients’ disability checks (which were sent to the agencies, since the clients had no fixed address) until after the buses returned to the agency in the afternoon, after the rally. This deviated from the normal practice of giving clients their checks as soon as they entered the day shelter. A social work student placed in one of these shelters questioned the ethics of withholding clients’ checks and noted how inconsistent this was with the social work goal of promoting client empowerment. However, agency personnel viewed this as a necessary tactic to “encourage” clients to advocate for themselves. In addition, while organizers believed that all people without housing were entitled to services, they directed media attention toward women and children because they assumed that these clients would generate more sympathy. Community members perceived as supposedly more deserving of assistance may be more persuasive to decision-makers, but this is inconsistent with the ethical principle of the dignity and worth of all individuals. One of the clients without a place to live who had agreed to speak on camera—a young black woman with two young children and a history of drug addiction—unexpectedly broke down while she was being interviewed, revealing her despair and desperation. Some organizers believed that her obvious anguish bolstered their cause. Others, including the social work student, were embarrassed for the client and worried that the professionals and the media had exploited her pain. She and her classmates also felt that her selection as a “face of homelessness” reinforced negative stereotypes of this vulnerable and oppressed population. As these issues reveal, social workers often face ethical challenges when they engage in community practice. While personal stories may be persuasive to decision-makers and the general public, we must consider and prepare individuals for the risks that may accompany their openness. This accentuates the importance of informed consent. Further, psychological impotence is a powerful force that works against marginalized individuals working collectively. This underscores the need to employ skills that mobilize individuals to act in their own interests. However, as much as we may want these individuals to act on their own behalf, we must question the use of strategies that force them to do this.

Influencing the Practitioner’s

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Organization

The Life Model of Social Work Practice broadens the concept of professional function to include influencing the worker’s own organization to improve services, correct maladaptive transactions between staff and between staff and clients, and increase responsiveness to the needs of the population that it serves or is expected to serve. Social workers continuously assess the impact of their employing organization’s presence in the lives of actual and potential clients.

SOCIETAL, PROFESSIONAL, AND BUREAUCRATIC FORCES

Chapter 9 discussed how lack of fit between organizations and clients could become a potent stressor for individuals, families, and groups. We identified the professional roles, tasks, and responsibilities associated with enhancing clients’ ability to negotiate their social and physical environments and to be more responsive to their own needs. In this chapter, we focus on the worker’s efforts to improve an organization’s willingness and ability to respond to its clients’ needs. Our efforts may be prompted by our work with specific clients, but our intent is to improve the organization’s responsiveness to all clients.

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Organizational influence also includes challenging a toxic work environment and promoting one that encourages staff creativity, involvement in decision-making, and a climate of validation and recognition of staff contributions. As discussed in chapter 9, we must question how effective social workers can be at helping clients if they themselves feel powerless to effect change in their work environments. Sources of Maladaptive Transactions between Employing Organizations and the Clients They Serve

Chapter 9 discussed how organizations could create stress for individuals, families, groups, and communities. For the reader’s convenience, we summarize and briefly elaborate upon the topic again here. External Organizational Stressors Sources and Level of Funding

Public funding for services, particularly those that respond to the needs of disadvantaged and marginalized clients, reflects the distinction between “worthy and unworthy” poor and public misperceptions about the presumed tax burden that such services impose on society. Concrete services, in the form of financial aid, subsidized housing, and social services like counseling, often are provided in a demeaning manner, and in settings that are uncomfortable and staffed by insufficiently trained personnel. In addition, services often are limited in scope, inadequate to meet clients’ needs, and require long waits to receive. Funding trends shape organizations; funding may become available in one area, leading agencies to respond with new programs that replace other programs, regardless of client need. Certain problems receive public attention, while others are overlooked. When one problem increases in visibility and another recedes in the public eye, financing may shift in response. Some agencies may hold onto familiar services and procedures, either due to restricted funding or to an unwillingness to respond in new ways to clients’ changing needs. Demand for Accountability

Social service organizations are confronted by an increasing emphasis on accountability, which, as discussed in chapter 1, can undermine workers’ ability

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to respond to the unique needs of their clients. Decisions regarding the type and length of services reflect third-party payers’ reimbursement requirements rather than professional judgment about what a particular client needs. Community groups also may demand accountability for an organization’s services and practices. Additional sources of accountability include an organization’s board of directors, other organizations on which the agency depends for referrals and funding, and public and private licensing and standard-setting bodies. Internal Organizational Stressors Authority Structure

Organizations depend upon a chain of command or levels of authority to coordinate the various subunits and personnel, specify responsibility and accountability, and provide leadership in decision-making. Different positions in the hierarchy have different priorities and interest groups to please, which can create tensions and turf struggles. Social workers often occupy the lowest position in the hierarchy, which often means that they have limited authority, insufficient information, and inadequate opportunities to influence organizational processes. Rigid authority structures prohibit the flow of communication between those lower in the hierarchy and those higher up, or they may be unidirectional (communication flows from the top down, with little or no explanation). This stifles initiative and creativity. A rigid authority structure also may discourage staff differentiation and specialization, which undermines their ability to respond to clients’ unique needs. For example, in the Brentwood Neighborhood Agency, the director is unable or unwilling to delegate tasks and responsibilities to staff. She is involved in so many activities and projects that she cannot handle them all properly. At the same time, her staff have inadequate information for performing their functions and require her approval for every detail of their work. The agency’s general inertia and the staff ’s diminished investment in the program have led to an increasing number of clients dropping out of the program and a high rate of staff turnover. In contrast, ambiguous or loosely organized authority structures leave it unclear who is in charge and discourage coordination and accountability. Staff may have too much autonomy, resulting in limited supervision and little to no oversight or demand for accountability. Services remain uncoordinated, and workers essentially practice privately, on their own. Professional role definitions

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and expectations are specialized and narrow, encouraging isolation, or they are ambiguous and overlapping, resulting in internal competition. Agency policies and procedures may be overformalized or underformalized. Outdated rules may be imposed in new situations, while policies favorable to client needs may be systematically ignored. Division of Labor

Organizations also require a division of labor to coordinate service activities. When role assignment is rigid or too specialized, this can lead to preoccupation with developing and maintaining one’s own niche. Client needs are held hostage to turf interests, as professionals disagree over who “owns” the client. Division of labor among organizations also can create problems for clients. Service arrangements may be inadequate or inaccessible because of individual agencies’ definition of purpose and service. For instance, patients who are making the transition from inpatient care in a psychiatric hospital back into their community are seen at the Eastern Community Mental Health Center. However, the center does not provide assistance with the adaptive tasks needed for its clients’ successful reintegration into the community. These patients do not fit into either the inpatient or outpatient department. What is needed is a transitional service or a day hospital program for soon-to-be released hospital patients. Professional Role and Self-Interest

As professional social workers, we require a certain amount of autonomy so that we can carry out our responsibilities in a way that responds to the unique needs of our clients. To advocate for our clients’ interests effectively, we need to work through the layers of bureaucracy in our organization. Unfortunately, organizations may stifle workers’ independence and creativity due to their hierarchy and chain of command. Individuals higher up in an organization may refuse to hear the concerns of those lower in the hierarchy. While social workers often are in the best position to understand client needs, they may be unable to act on them because of their lower standing in the organization. Further, professional interests do not always match client interests. Workers may tolerate undesirable work conditions that negatively affect both them and their clients because of high salaries, good benefits, and/or job security. Practitioners’ need for job security and protection of their reputation may prevent them from challenging the organization when clients’ interests are

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ignored. These tacit agreements often lead to identification with the organization and its practices and procedures, as opposed to a focus on serving clients. Socialization of the social work student occurs within a pattern of expert-novice field instruction, where power and authority is vested in the supervisor and the agency. This may inadvertently encourage organizational loyalty and discourage risk-taking. As holders of the lowest position in the professional hierarchy, students have little power to exert change within their field placement. They may carry this experience over into their careers, even when their professional position may provide them with more power and influence. Agency Definition of Professional Purpose

Agency and professional definitions of social work purpose have a strong impact on clients. When an agency is characterized by divergent professional orientations, clients may be held hostage to competitive interests, struggles, and discrepant practices. Yet when an agency adheres to a single orientation, clients are often expected to fit within that approach. Similar to composing a group, an organization should strike a balance between divergent staff orientations (heterogeneity) and a common underlying staff orientation (homogeneity). When agencies view a client’s life stressors as located in the person, external forces are likely to receive insufficient attention. This results in service definitions and styles that are unresponsive to the full range of client needs. When agencies’ purposes and services are ambiguous, clients fall between the cracks because no agency appears responsive to their particular situation. In other instances, services might be available, but the method and style of delivery discourage their use, such as in the following situations: Jackson Adolescent Health Center has a 44 percent no-show rate for applicants scheduled for intake interviews. The center has not attempted to reach out to this applicant pool, although some workers informally follow up on a case-by-case basis. The procedure is largely limited to informing a referral source that an adolescent did not appear for an intake. Therefore, the reasons for the “no shows” remain unclear. Longshore Community Services, a sectarian family agency, limits its intake to self-referrals. The agency does not attempt to make itself visible in or accessible to the community. Because the agency offers no outreach services, many clients who could use and/or need the agency’s services do not even know it exists.

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SOCIAL WORK FUNCTION, MODALITIES, METHODS, AND SKILLS The Social Worker and Life-Modeled Organizational Practice

Some social workers maintain a distance from their organization, as if they were in private practice. They see clients, do their jobs, and go home at the end of the day. Other workers identify completely with their organizations. Either of these extremes compromises clients’ interests. Still others overidentify with the client, as if the agency were their mutual enemy. This stance is sustained at the risk of alienation— or even dismissal—from the agency, which also undermines clients’ interests. We propose that social workers must identify simultaneously with their organization, their clients, and the profession in a three-way mediation among clients’ needs, organizational requirements, and professional purpose. Social workers are sensitive to indications that organizational processes are inconsistent with client needs. When such processes become problematic, social workers committed to ethical and life-modeled practice pursue modification of the maladaptive practices, procedures, or programs. Consider the following two examples: A recent graduate, William, described what he thought was an unethical and potentially illegal practice in his agency. He worked in an agency that provided services to clients with substance abuse stressors, and many of his clients also had histories of sexual abuse. As required by the law in his state, William reported a client’s history of sexual abuse to the local department of social services and noted this in the client’s record. His immediate supervisor called him to the office and informed him that his actions were “unethical” because he had violated the client’s right to privacy. William responded that his understanding was that state law mandated such a report; he explained the steps that he had taken, which included informing the client of the mandate prior to making the report. The supervisor said that “that was news to her”— though the mandate had been in place for a number of years—and instructed William to make a report only if he suspected a child was at risk. The supervisor explained that if the agency was forced to report past abuse of its clients, this would “scare them away.” By ignoring the state’s expanded mandatory reporting requirement, William— and the agency—were at risk of both civil and criminal liability. The dilemma he faced, however, was what to do, since this was his first job out of graduate school and he was concerned about repercussions if he were to take action. He decided to go back to his supervisor and inform her that he had researched the issue further and the agency did have a mandate to report any client with histories of abuse. William matter-of-factly explained what the agency’s legal responsibility was. The supervisor

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remained adamant that it was in their clients’ “best interest” to avoid the mandate, “if it even was real,” and she prohibited the new social worker from making a report in these cases. William then informed his supervisor that he remained concerned about the agency’s liability and felt compelled to report his concerns to the agency director. The supervisor reluctantly supported his actions. The agency director said she would learn about the agency’s obligations with respect to reporting clients’ history of abuse and expressed appreciation for William’s feedback. Alicia was worried that one of the social workers at her agency was having an affair with a client; she had seen the two at a local restaurant being “very affectionate” with one another. She was not sure what to do, since she knew that her field instructor and this worker were friendly. After discussion with the field director at her school, Alicia decided to start with her field instructor, knowing that should this meeting not go well, the school would step in and advocate for her. The field instructor was shocked by what Alicia described and agreed that, at minimum, the social worker had engaged in a boundary violation. The field instructor took the student’s observations to the director of social work, who in turn met with the social worker and shared with him what had been observed, without revealing where the information came from. While the nature of that conversation was confidential, the student noted that the worker left the agency soon after her report.

In both cases, the workers encountered situations that they believed were problematic and did something about them. Both initially took steps that involved minimal risk to them and used the organizational hierarchies. In the first case, the social worker, William, understood the risk that he was taking in going above his supervisor to the agency director. His newness to the profession and his job both made it easier for him to do the right thing, as did his understanding of the liability he and his agency would face if they did not adhere to a legal mandate. The second case reveals how a sensitive situation should be handled to protect the whistleblower as well as the target of the complaint (in this case, the social worker who was seen in a restaurant with a client). We now turn to the methods and skills of influencing employing organizations through preparation, initial organizational analysis, entry, engagement, implementation, and institutionalization. Preparation Phase

Problem identification and documentation. Preparation begins with the identification of an organizational problem. Clients often are the primary point of

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reference. In some cases, workers may identify an organizational problem or barrier to services that clients may not yet have identified. Workers obtain data about problematic organizational arrangements and practices by attending to clients’ direct and indirect expressions, reviewing records, and compiling other information. Colleagues are another resource. By attentive listening and observation in staff meetings, in-service training programs, group supervision, and informal conversations, the worker learns of maladaptive organizational patterns. This process of systematic observation, formal data collection, and informal conversations is analogous to the social planning approach in community practice described in chapter 14. Consider the hoped-for outcomes and means of achieving them. Once workers identify and document maladaptive organizational patterns, they consider alternative solutions or objectives and the specific means for achieving them. The social worker then carefully examines the advantages, potential consequences, and feasibility of each potential hoped-for outcome. Based on the initial appraisal, a tentative objective and specific means for achieving it are determined. The following vignettes illustrate the preparation phase. Medical Hospital—Surgical Floor

Problem: Definition of Social Work Function. Social work practice is limited to discharge planning. All other patients, regardless of their need for social work services, are overlooked. Documentation: One woman, distraught over a planned amputation, was not referred because the family could take her home right after surgery. Another woman in the terminal stages of cancer and severely depressed was not referred because her sons were making discharge arrangements. Desired outcome: Expand the social work function to include high-risk situations such as these. Means of implementation: Broaden the agenda of team meetings to include identifying high-risk patients. Transitional Housing for Chronically Mentally Ill Clients

Problem: Coordination and Integration of Structures and Procedures. There is insufficient coordination among staff. Documentation: Residents constantly complain about staff lateness, the service and quality of meals, inequities in house assignments, inadequate protection from residents who steal or are physically abusive, and hostile and demeaning

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behavior by staff. Staff complaints include residents’ failure to cooperate, administration’s insensitivity to staff needs, and ineffective coordination of services. Lack of enforcement of house rules and regulations is also a staff complaint. The director, on the other hand, locates the problem in the lack of staff initiative, creativity, and assertiveness in carrying out programs and policies. Desired outcome: Improve internal operations of the house and communications among the three groups. Means of implementation: Obtain a commitment to and approval for creating an advisory staff group to consult with the director. Once the advisory group is in place, add residents and redefine the group as a house council. The worker defined the problem as lack of structure and procedures for coordination and devised a means for integrating the various parts of the house system. If the director’s definition of the problem remained in place, the worker might also have sought to improve staff performance through in-service training. Adolescent Health Clinic

Problem: Services Provided. The clinic’s intake practices discourage many adolescent applicants from using its services. Documentation: A review of the intake log over a six-month period revealed the actual numbers of intakes scheduled and no-shows. The no-shows were further analyzed by the number of rescheduled appointments. In the six-month period, 465 adolescents had intake appointments, and 208 (45 percent) failed to appear. For the first rescheduled intake appointment, 133 (29 percent) failed to appear. Only 38 (8 percent) called to cancel or reschedule their appointments. The targeted change focuses on applicants who make no attempt to communicate on their own. Desired outcome: The objective is to increase professional staff involvement with applicants, with the ultimate goal of increasing the number of applicants who become clients. Means of implementation: Professional staff will be involved by initiating a call to remind each applicant of an upcoming appointment and a follow-up call to each no-show applicant (if self-referred), or the no-show applicant’s referral source. Such phone calls may provide a bridge into the clinic. Senior Center

Problem: Service Arrangements. The programming for attendees at the center is poorly planned and carried out.

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Documentation: Regular attendees complain that programs are canceled, guest speakers do not arrive for announced lectures, and most activities are dull. The social work intern’s observations are similar. Fewer clients are attending the center and there are no new clients. Desired outcome: Improve the quality of social programs. Means of implementation: Obtain approval for and organize a steering committee of regular attendees, personnel from other agencies that serve aged clients, and interns to plan programs. In this setting, a steering committee is congruent with organizational norms. It is not a radical innovation, and it invites a broad representation of participants, particularly clients who have been attending the program. It is hoped that as clients become involved, their influence over programming will increase. The new arrangement is likely to have permanent impact. Community Social Services

Problem: Services Provided. The agency’s intake practices discourage many applicants from using its services. Documentation: Telephone calls to a small, random sample of people who had failed to show up for their appointments, or refused to make an appointment after intake, yielded initial data. Complaints included lack of evening hours, a lapse of several weeks between intake and assignment to a social worker, the demand to fill out numerous research forms, and intake clients’ discomfort with the psychiatrist’s detailed questions concerning sexuality. Desired outcome: Increase the responsiveness and relevance of the intake service to client needs. Means for implementation: An ad hoc committee was created to study the high dropout rate. Ad hoc committees—created on an as-needed basis—are important structures for revising agency practices and programs. A direct assault on the agency’s intake services can generate resistance. In this case, the agency prided itself on its evidence-based approach and had a full-time researcher, so the proposed committee was consistent with formal and informal norms. Composition of the ad hoc committee will be important if change is to occur. Committee members must enjoy sufficient flexibility to entertain proposed changes in intake arrangements and sufficient respect to influence their colleagues. Table 15.1 summarizes the preparation skills used to influence an organization. Engage in organizational analysis. Having tentatively identified and documented an organizational problem and selected an objective and means for

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Table 15.1 Preparation Skills: Organizational Change Obtain data to identify and document organizational problems.

• Clients’ direct and indirect expressions of concerns, review of agency records • Informal conversations with colleagues • Formal participation in staff meetings • Systematic data collections

Consider desirable outcomes and means achieving.

• Avoiding mobilizing the organization’s defenses • Identifying staff self-interest • Assessing the feasibility of proposed outcomes and means of achieving those outcomes

achieving it, the worker then undertakes a formal organizational analysis. A force field analysis helps the practitioner to identify and visualize the specific forces promoting and resisting change (Brager & Holloway, 2002). The worker assesses which environmental, organizational, and interpersonal forces are apt to support the proposed change and which are apt to resist change. A summarized sample of a force field analysis is presented in appendix D. The social worker identifies aspects of the organization’s external and internal environments that can either work for or against the proposed intervention. Environmental forces include sources of funding, funding trends, and demands for accountability. A financially troubled agency, for example, may be receptive to changes in intake policies and procedures that reduce costs or expand the fee base, even though such changes are contrary to its ideological orientations. Organizational forces include the division of labor and the authority structure. Organizations with a number of professional disciplines and staff characterized by diversity, openness to new methods and technologies, and competing interest groups often allow innovation. Organizations that are highly centralized, with power located in a few elites, or are highly formalized, with a large number of codified rules, are less likely to allow innovation. Workers can use knowledge of these organizational properties to assess potential obstacles and barriers to their proposed intervention. Figure 15.1 portrays the combined impact of organizational complexity and formalization on receptivity to change. In agencies characterized by a low degree of complexity and a high degree of formalization (designated as C in the figure), workers are likely to be more successful if they establish narrow objectives and limit desired outcomes to

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(+) = Increasing Feasibility (–) = Decreasing Feasibility Complexity Formalization

Low

High

Low

– + (A)

+ + (B)

High

– – (C)

+ – (D)

Figure 15.1 Impact of organizational complexity and formalization upon change

procedural changes such as enforcement of existing rules favorable to clients or suggestions of new procedures to replace outdated ones. Modification of organizational purpose or basic programs is unlikely in programs such as these, which include public departments of social services and child welfare, Social Security, or correctional and forensic settings. In contrast, a worker employed by a highly complex but less structured agency (B) may aspire to greater functional, structural, or programmatic changes. In community mental health centers, homeless shelters, or family service agencies, the worker can often undertake more ambitious influence efforts. While a particular organization may have overall features of high complexity and low formalization, a department within it may not share those characteristics. For this reason, the organizational analysis must include the subsystem and its relation to the larger system. Strategies to influence agencies characterized by low complexity and low formalization (A) or by high complexity and high formalization (D) are less straightforward. In a relatively undifferentiated community agency, for example, services may suffer from a lack of staff diversity and narrow ideological commitments. While workers may be unable to directly influence the purpose and program of an organization that is low on complexity, they may have sufficient support and resources to have an indirect influence. A consultant, for example, might be used to expose staff to new knowledge and technology. In addition to external and internal influences, the worker attends to interpersonal forces. Practitioners need to identify key participants who will affect and be affected by the proposed change. The worker also observes staff behaviors during formal and informal contacts by looking at patterns (risk-takers, conformists, or “closet” advocates); norms (individual and collective values);

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activities (job responsibilities and outside interests); and motivation (what constitutes satisfaction and stress for each person). Workers then anticipate each participant’s likely response to the proposed change and evaluate its probable impact on job performance and satisfaction. If the desired outcome and means of achieving it support participants’ self-interest by increasing their prestige, autonomy, influence and/or authority, their support is more likely. Conversely, if the desired outcome and means threaten participant self-interest, then resistance may be anticipated (Brager & Holloway, 2002). Social workers also consider their own personal influence based upon their formal position in the organization, as well as any informal sources of influence they may possess. Chapter 9 described a case in which a social work student, Juanita, attempted to advocate for her client, who had left her ward in the psychiatric unit and was found on the men’s ward. Juanita expressed great anger at the treatment team for taking privileges away from her client as punishment for her action, and her field instructor was required to intervene. Although the field instructor was lower on the hierarchy than other members of the team, his reputation and the members’ respect for him contributed to his ability to advocate for the client and for Juanita as well. Social workers interested in influencing their organizations also must assess how others view them in the organization. In developing organizational self-awareness, practitioners must try to see themselves as others do, rather than as they would like to be seen. They need to evaluate the extent to which others view them as competent and valuable colleagues. Finally, workers must consider their stockpile of time and energy, since the tasks involved in seeking change require an abundance of both. Through analysis of organizational forces, social workers can evaluate the potential for success of their proposed effort to influence the organization. When supports are strong and opposition is weak, feasibility is high. When support is weak and opposition is strong, feasibility is low. A change in the means for attaining the desired outcome often increases feasibility without compromising the objective. Table 15.2 summarizes initial organizational analysis skills. In the earlier example of the senior day program’s inadequate programming, the worker initially had intended to hire a professional consultant. Her analysis, however, revealed powerful constraints that were likely to lead to resistance from the department. The less threatening strategy of a steering committee comprised of agency staff diminished the resistance and heightened the feasibility of the proposition. When supports and opposition are both weak, it is likely that supportive elements will have to be mobilized. Both strong support and strong

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Table 15.2 Initial Organizational Analysis Skills Assess the environmental forces likely to support or constrain the proposed change.

• Examine the impact of societal, technological, legislative, community, and physical contexts.

Assess the organizational forces likely to support or constrain the proposed change.

• Examine the extent of complexity, centralization, and formalization of the total organization or a specific department. • Evaluate the combined effect of organizational forces.

Assess the interpersonal forces likely to support or constrain the proposed change.

• Identify key participants.

• Evaluate the effect of the proposed change on key participants’ job performance and satisfaction (prestige, self-esteem, autonomy, influence). • Evaluate key participants’ interactional patterns and organizational activities. Assess the elements of worker influence likely to support or constrain the proposed change.

• Evaluate one’s formal position in the organization. • Evaluate one’s personal position in the organization. • Evaluate one’s amount of time and energy.

Assess the feasibility and potential for success.

• Strong supports and weak opposition suggest high feasibility. • Weak supports and strong opposition suggest low feasibility. • Weak supports and weak opposition suggest an open situation. • Strong support and strong opposition suggest possible conflict.

opposition indicate the potential for conflict. The outcome is unpredictable, suggesting that a low-keyed approach is more likely to be successful. Entry Phase

Engage in anticipatory empathy. To develop a receptive organizational climate, we use anticipatory empathy to explore with staff their thoughts and feelings

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about the organizational problems that we hope to address, as well as our proposed solutions. For instance, in the sectarian family agency, the social worker observed: I was aware of staff concerns about declining intakes and their fears of staff layoffs due to funding cuts. During informal discussions with staff members, I encouraged conversation about the decline in intakes and the effect on the agency. I felt out their attitudes and thinking on the subject and their possible reactions to alternative solutions. I dropped hints about possible outreach to the community. I mentioned a suggestion made by a respected and well-liked administrator from our central office to offer group services to lesbian, gay, bisexual, transgender, and queer/questioning clients, since this was an underserved population. I also invited their thinking about active outreach and collaborative projects to increase the agency’s visibility in the community.

The worker began informal discussions with organizational allies, testing possible reactions and inviting their ideas in collaborative problem-solving, which worked well. In contrast, an attempt by a social worker assigned to a psychiatric impatient service to have patients decide on how to use their passes failed at the outset: At the conclusion of the case conference, I brought up the issue of patients’ passes and suggested that patients be involved in how they could use them. The nurses immediately voiced their disagreement, and the psychiatrist told me I had to present my idea to the multidisciplinary clinical team. The meeting ended without any support for my idea.

The worker took premature action in the formal system without having first scouted out potential sources of support or resistance. This mobilized team members’ opposition and precipitated immediate rejection. Support for a proposed innovation or change must be developed and cultivated before it is made public. In another example, two social workers were concerned about a policy instituted by their agency’s board of directors that prohibited them from discussing birth control or providing contraceptives to their adolescent clients, required them instead to promote abstinence. This policy was inconsistent with the agency’s stated mission, which was the prevention of teen pregnancy. Initially, they went to the agency director and requested that she make an appeal to the board of directors and explain that an abstinence-only policy was inconsistent with the

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agency’s mission to reduce teen pregnancy. The director refused, stating that she had been hired by the board and could be fired by them as well. The workers decided to appeal to the board members directly through e-mail. In the e-mail, they cited research supporting the efficacy of promoting birth control and safe sex practices and indicated that they were making the appeal on their own. They copied the e-mail to their supervisor and the agency director. The chairperson of the board replied with a curt e-mail informing them that they must follow “standard procedures” and lodge their complaints with the director. While the workers had facts on their side, they had not cultivated a receptive environment for their concerns with either the agency director or the board of directors. Establish a Receptive Organizational Climate

Brager and Holloway (2002) suggest three methods of preparing a system: personal positioning, structural positioning, and the creation and management of discomfort. Because practitioners usually have limited formal authority, their organizational effectiveness depends upon personal positioning. Professional competence is a major resource and “immediately precludes or mitigates easy dismissal of one’s ideas and opinions” (Gitterman and Miller 1989 p. 160). The first positioning task is illustrated by a social worker’s effort to achieve visibility within her agency: I had been prompt and attentive in doing weekly intakes for several months. I involved Mr. Phillips, director of intake, whenever I had a question about a procedure. I recently completed an intake on behalf of the husband of another client seeing an experienced worker. I consulted with the worker and shared my assessment of the case. She complimented my work and apparently discussed it with the director of intake and the agency director, both of whom mentioned the good work I was doing.

Being seen as competent means that our knowledge and expertise are respected and valued, enhancing our credibility and influence. The social worker who is an insider, pays attention to colleagues’ interests and concerns, and possesses interpersonal skills will acquire a support system and organizational allies. An isolated practitioner who deviates from informal norms will have limited resources for influencing organizational practice. Structural positioning involves workers’ efforts to identify individuals who have the formal authority and informal power to effect—or block—change efforts. The social worker considers which formal and informal processes may

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facilitate or block change efforts and then settles on the most effective individual or individuals to introduce the idea. We may be the ones who initiate a change strategy, but we must be prepared to rely upon individuals who are influencers to bring our strategy to fruition. Despite the fact that the two social workers in the previous example about the birth control issue had a strong case for their desire to reverse the policy initiated by the board of directors, they had not cultivated support for their position. They also had not developed a strategy to tackle the agency director’s concern for her job security, which was a significant impediment to their efforts. In addition, we should consider involving clients who are or will be the beneficiaries of our proposed change efforts. Their opinions can be secured through brief surveys and formal and informal interviews. Not only is this empowering to clients, it also ensures that our efforts truly reflect clients’ needs. We return to the social worker in an outpatient program serving children and adolescents who sought to increase the number of adolescents seen by her agency. Few adolescents or parents sought services, possibly because of the agency’s name (Children and Family Services), as well as a lack of publicity and outreach and the reluctance of staff to get involved with what they perceived to be “obnoxious teenagers.” Her first step in influencing her agency to live up to its objective was to interest the director in forging links to the local middle school as a way of increasing agency income. With the director’s permission, she approached the principal and guidance counselor with an offer of providing group services to interested students. Together, they designed a questionnaire, which was distributed to students in their social science classes. Responses were mostly positive. Armed with this data, the worker and the clinic director collaborated with school personnel and obtained parental permission. The worker’s initial objective was to provide group services in the school, with the longer-term goal of making services to adolescents an integral part of her agency’s service offerings. Because agency staff had expressed reluctance to work with adolescent clients, the director planned a series of in-service workshops for staff—for which they could earn continuing education credits required for their licenses—to enhance their comfort with and skill at engaging these clients in working relationships. Many social service agencies and hospitals often ask clients and families to evaluate the service received. This data can be an important source of support for efforts to influence one’s organization and communicates to clients that their opinions are valued and useful. In some instances, clients play a critical role in the influencing process. For example, a children’s developmental disability clinic within a hospital was threatened with closing when a new administrator changed the hospital’s

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fiscal and service priorities. The clinic had been providing group services to the parents of children with disabilities, and the group members were eager to contribute to staff efforts to sustain the clinic. Members mobilized a telephone and e-mail campaign among their friends and neighbors, and they interested a local radio station and a neighborhood newspaper in their plight. Staff drew up proposals for funding that were realistic and would not “break the budget.” The administrator agreed to withdraw his plan to dismantle the clinic. Services to the children and their parents were safeguarded, and parents felt empowered, since they were integral to the effort. In another example, a family agency social worker was concerned that her agency did not offer evening hours. She obtained the director’s permission to invite several interested clients to a staff meeting, and later to a board meeting. In such instances, the clients’ presentation of their own needs was more effective in influencing staff and policymakers than the worker’s presentation. Similarly, a child welfare agency that had been reluctant to offer group meetings to foster parents was influenced to do so by a worker’s carefully thought-out proposal of content for the meetings and her mobilization of the support of many foster parents, who then called and wrote to the director about their interest. Users of the service must be fully informed of all that is at stake in their active participation in (or even in their passive support of) an influencing effort. The positives inherent in successful influencing are easy to identify and share. The possible negative consequences for clients must nevertheless also be considered and shared with them so that they may make an informed decision to participate or not, consistent with the ethical principle of informed consent. Organizations can erect elaborate defenses by which an organizational problem can be rationalized, minimized, avoided, or denied. Before motivation can exist to examine and modify maladaptive practices, structures, and procedures, the worker may have to create discomfort among members of the organization. An important task in the entry phase is to bring the problem and its ramifications for clients—and, if appropriate, the organization—to the participants’ consciousness by increasing its visibility. For example, a worker in a family service agency recorded: I made sure the director knew about the problems all staff were having with the scheduling of psychiatric consultations. I highlighted a recent experience I had with a client who waited two hours and then still wasn’t seen. The director was disturbed by this incident. I also shared my clients’ experiences with other staff members, which stimulated their interest in and concern about the issue. Before long, several workers asked that the issue be placed on the agenda for a staff meeting.

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Through both formal and informal contacts, the worker listened to others’ dissatisfactions and encouraged conversations about the problem. Heightening discomfort among others is often an impetus for them to initiate action and for others to listen and respond. At times, data can be sufficiently compelling to create organizational discomfort. In the adolescent health clinic in which intake practices discouraged many adolescent applicants from using services, the worker analyzed the no-show data. Self-referred applicants had the highest no-show rate for the initial appointment, at 69 percent. Because self-referral usually implies that clients recognize there is a problem and are motivated to seek help, this anomalous finding prompted the agency to examine its intake structures and processes. If the discomfort is excessive, an agency or department staff can become overwhelmed by conflict or hopelessness. The stress itself can lead to paralysis and become a constraining force. The worker needs to specify the problems and help staff mobilize to solve them. A hospital medical team, for example, was unable to work together effectively to provide coordinated patient care. The worker attempted to reduce stress by suggesting that the source of the problem was organizational rather than interpersonal. She began with nonmedical staff, the most alienated group, affirming their value to the team and strengthening their respect for their professional and organizational roles. The worker reports: We were sitting around chatting when Phyllis, an occupational therapist, asked me what I thought of the new batch of medical residents. I said I missed the old ones. Jean, a physical therapist, agreed and added that the new ones “don’t seem to care what anyone else has to say. Half the time they don’t know what’s going on with their patients.” I asked if that’s why she stopped coming to medical rounds. Phyllis acknowledged there was no point going, and Jean added that no one wants to hear what she has to say. I said it was a real problem when staff didn’t communicate, pointing out, “You know more about patients in some ways than we do because you spend the most time with them.” Jean responded, “You know that, but they [residents] don’t.” I said not coming to rounds isn’t the answer because then no one talks to one other, and patients will suffer. Everyone agreed. Alice, another occupational therapist, said her impression is that no one is interested in what she does. I asked her to elaborate, and she described how the residents ignore her and devalue her work. I praised her program and skills, offering specific examples of the impact she had made. I also pointed out that she isn’t the only one feeling this way. It seems that all of the nonmedical disciplines are questioning their value in rounds, citing social work as a case in point. Alice

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thought about this and agreed there did seem to be a general problem; no one talks except the residents. Jackie, another social worker, suggested that people’s anger with one another had developed into personality clashes. I suggested that it seemed to me the problem was one of communication among the team members. Everyone agreed. I said things are not going to get better unless we talk about the problem: “Discussing personality conflicts won’t get us anywhere. Perhaps there is another way to approach it, through improving communication in rounds—because that really is the problem.” Then, we all began to talk about how we could defuse the problem.

As the staff members depersonalized the struggle, they began to function with greater energy and resourcefulness. The positioning task was to reduce the stress so that this problem, which initially seemed so overwhelming, could be confronted. In the process of redefining the problem as organizational, the social worker gained important allies in dealing with it. Table 15.3 outlines the skills used in the entry phase.

Table 15.3 Entry Phase Skills: Organizational Change Create receptive organizational climate.

• Engage in anticipatory empathy. • Informally discuss the problem with friends in the organization. • Develop informal support for problem identification.

Achieve influence through personal positioning.

• Demonstrate professional competence. • Actively participate in interpersonal networks.

Achieve influence through structural positioning.

• Actively participate in formal organizational structures. • Engage service users.

Bring the problem to the awareness of organizational participants.

• Increase the visibility of the problem and its consequences for the clients and the organization. • Create discomfort. • Decrease excessive stress by specifying the source of the problem. • Help staff to mobilize to solve the problem.

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Engagement

After establishing a receptive organizational climate for the formal introduction of the identified issue and the proposed solution, the worker must decide on methods, including demonstrating, collaborating, persuading, and creating conflict (Brager & Holloway, 2002). The action taken depends on the type of issue, the degree of goal consensus between the worker and critical participants, and the worker’s resources for influence. Decisions in this regard parallel those that accompany community practice. Demonstration and presentation. These skills are especially effective when the issues reflect professional practice and program gaps. For example, broadening the conception of an agency or department’s social work function or introducing a new modality is best achieved using the reasoned, logical strategies embodied in social planning. By persistently and skillfully showing through action the value of group services, a social worker with limited organizational resources (rank), but sufficient personal resources (competence, energy, and being held in high regard), may neutralize rather than mobilize organizational resistance. Demonstrating should include, whenever possible, a cost-benefit analysis: whether the costs associated with the proposed intervention outweigh the savings associated with its benefits and/or the costs associated with not initiating it. A recent graduate began professional employment in Rainbow House, a residential facility serving 20 adolescents. The agency’s objective was to prepare the residents for independent living when they were no longer eligible for substitute care. Residents were understandably cynical and resentful about having been bounced from foster home to foster home and from a group home to a residential treatment institution. Rainbow House reinforced their sense of powerlessness by excluding them from decision-making regarding their future. Although the agency emphasized “empowerment,” it limited this focus to helping clients to manage their feelings of loss and fears about their future in their individual treatment sessions. Being denied a voice in decision-making replicated a life pattern of institutionalized helplessness and dependency and sabotaged the agency goal of preparing residents for independent living. A frequently heard statement, “I just want to do what I got to do and get out of this place,” concealed residents’ fears of final discharge and independent living. When they did complain about their treatment at the facility, they focused on the particular issue at hand, not on the fact that staff made all the decisions. The professional staff attributed the

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residents’ complaints to feelings of abandonment and attachment issues, while the childcare staff attributed them to the residents’ general immaturity and distorted sense of entitlement. The worker’s desired outcome was to develop a youth council of residents to plan programs and discuss their concerns with staff. As a new worker, she cautiously broached the idea with a few influential staff members. Their response was unenthusiastic. However, within a few months, Rainbow House experienced several traumatic events. A well-liked staff member’s disability caused him to quit his job; a skillful senior childcare worker engaged in a fight with a resident and his employment was terminated; and a respected professional staff member left for a new position. These changes were devastating to both staff and residents. The social worker used the organizational crisis to gain staff and resident approval for weekly meetings of a youth council for a six-month trial period, asserting that the involvement of residents in decision-making would reduce the turmoil that the agency and its staff was experiencing. He proposed six months as a sufficient period of time to demonstrate to the director that the members would act responsibly and the organizational climate would improve. He listened to the director’s concern, which was that if residents acted collectively, this would be disruptive. In response, the worker reassured the director that if he did not see positive changes in the allotted time frame, the council would be disbanded or reconceptualized. The worker acted quickly to hold Rainbow House’s first resident election of eight members to the youth council. The social worker invited a high-status and well-liked childcare worker to colead the council with him. This ensured childcare staff cooperation with the project. The weekly house meeting structure was implemented to present residents’ issues and concerns to the staff. The worker prepared members to present and discuss selected issues, guiding them in how to prepare and keep to an agenda, gain maximum participation of staff and residents, assign tasks and responsibilities, and involve other residents in the process. The director and childcare staff were impressed by the members’ self-expression and seriousness, and the director increased his support by providing the council with a small budget. When invited, he attended meetings. The youth council effected new policies and procedures and promoted a greater sense of community among residents of the program. The worker proved the youth council’s value to the organization by devoting equal attention to both organizational and council processes and the disciplined completion of tasks. After the initial six months, the youth council became an integral part of Rainbow House. This worker’s efforts are analogous to those that workers engage in community practice when they seek to help a community develop an

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ongoing leadership structure to continue the community’s efforts to improve its social environment and act in its best interests. Collaboration

Collaborating is effective in relatively open organizations, where goal consensus exists and there is either equitable resource distribution or the presence of close interpersonal relationships (Brager & Holloway, 2002). The social worker engages key participants in problem-solving through a shared search for data, possible solutions, and resources. Activity is low-conflict and involves providing relevant information and mild persuasion, without attempts to convince others or to change their positions. For instance, a worker in a children’s residential treatment center was concerned about ineffective handling of the children’s bedtimes. Children were ordered to bed by childcare staff, and some were assigned early bedtimes as punishment. The worker had a genuine appreciation for staff ’s concerns regarding low pay, overwork, and lack of appreciation. Because of her good relationships with staff, and her having a similar, lower-level status within the organization, the social worker reported that she selected the following methods of collaborating when she approached key staff with her concerns: 1. Psychiatrist: During a recent treatment team conference, I encouraged a parent to discuss her daughter’s complaint about being put to bed early. The psychiatrist agreed to look into the matter. At a subsequent clinical meeting, I presented my observations and concerns and received the psychiatrist’s commitment to placing the issue on a staff meeting agenda. 2. Childcare supervisor: After acknowledging the difficulties that she and her staff experienced in working with our client population, I shared my concerns and engaged her in thinking of ways to resolve the problem. She welcomed knowledge about the uses and effects of punishment. Since children are punished with an early bedtime for infractions that occurred in the morning or previous days, I described the results of behavioral studies on the lack of effectiveness of delayed responses to misbehavior. 3. Childcare staff: In an informal conversation I acknowledged bedtime as a troubling time for them to manage since many of the children were particularly difficult during this period, and I offered to work with them to seek solutions to the problem. As a result of these collaborative efforts, the childcare supervisor raised the concern in the staff meeting that she invited me to attend. A respected staff

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member, with whom I had developed a close relationship, said that whenever she had time to tuck some of the children into bed, their management was easier. A second staff member stated that telling stories was sometimes calming. They all complained about how they had little time for these activities. The supervisor suggested they bring unmanageable children to her. Staff was pleased with this structural change, and, in turn, agreed to tuck the children in. At the next meeting of the clinical and childcare staff, I suggested we spend a few minutes on how things had gone so far and asked for additional suggestions for easing the problem further. One childcare worker suggested that the recreation department could be useful in storytelling or singing before bedtime. The childcare supervisors and other staff agreed, and a meeting was arranged with the head of the recreation department. A program for this was developed. I asked staff to consider alternatives for punishment that we could discuss next week, and I agreed to inquire how other institutions handle discipline.

In this case, the worker used facilitating and guiding methods to engage key participants in collaborative evaluation, goal consensus, and problem-solving. Her use of data derived from relevant research is consistent with our definition of evidence-guided practice and with the social-planning approach. Persuasion

Persuading is effective in situations characterized by goal dissent and disparate power. The existence of a problem must be brought home to key participants, who then must be convinced that solving the problem is necessary and feasible. To influence the opinions and ideas of others, the worker relies upon five skill sets when developing and presenting the case for change and participating in debate. Issue definition is the important first task. The way that a problem and proposed solution are defined determines the grounds on which arguments will be based. The social worker has to develop arguments that demonstrate the existence of the problem, its severity, the effectiveness of the plan to deal with it, the benefits associated with eradicating the problem, and the risks associated with not addressing it. Second, issue definition must be supported by facts, illustrative material, and if possible, by the testimony of colleagues and clients. If a problem remains unrecognized, key participants will easily defeat or simply ignore any arguments about how to address it, as the following example illustrates. A social work student in a day program for seniors attempted to persuade an administrator of the

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need to be more proactive in helping clients apply for benefits for which they were eligible, but of which they were not taking advantage. She reflected on her mistakes: First, I assumed Mr. Johnson [the director] knew what I was talking about when I referred to a “senior benefits package.” Since he was not a social worker, he was unfamiliar with the entitlements that many of our clients could receive. Second, I failed to discuss the clients’ situation adequately. I did not utilize our agency’s mission and the administrator’s desire to follow the rules. I should have shared some of the challenges clients face, like large medical bills, lack of food, and poor housing. Third, I failed to provide statistics regarding the number of clients who are eligible for services but aren’t receiving them, and the challenges they face as a result. At the end of my presentation, Mr. Johnson said, “Although this seems like a worthwhile proposal, who’s going to do this? Your workload is already full, right? We do have handouts and posters all over the place letting clients know about social services they are entitled to, right?” I began to object, but he thanked me for my interest and dismissed me. I tried to facilitate our clients’ access to services they needed, without taking the first step in the persuasion process: establishing the need for the change.

Forces committed to the status quo address the problem either by denying its existence or minimizing its seriousness, underscoring the importance of the worker using relevant data to establish need. Third, the worker must anticipate and be prepared for opposition to the proposed solution and potential negative consequences. A one-sided argument, in which the worker lays out the justification and rationale for the proposed change, may be sufficient if the audience is likely to be persuaded by the worker’s presentation. This argument will be more persuasive if it appeals to the self-interests and value systems of key participants. If social workers anticipate resistance, they should consider presenting a two-sided argument (their own argument and the potential counterposition). The presentation is more likely to be persuasive if it is tailored to the language, perspective, and values of the audience. If needed, the worker can use the presentation to create audience discomfort, while at the same time conveying respect for and loyalty to the organization and its staff. Humor and role-play are effective in deflecting expected resistance or rebuttal (Heckelman, 2017; Cinite & Duxbury, 2018). Fourth, the worker uses the monitoring skills associated with social work practice with groups to assess individuals’ reactions and determine which positions are fixed and which are flexible throughout the persuasion process.

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Attending to individuals’ nonverbal reactions to our proposals enhances the likelihood that we will recognize signs of both resistance and support. Finally, we must remain open to modifying problem definition, proposed solutions, or the content and method of presentation in response to the ongoing appraisal of organizational representatives’ reactions. For example, we may broaden the proposed solution to encompass the interests of neutral participants. Conversely, we may narrow the proposal to eliminate the objections of a powerful participant. Our openness to refining our proposal requires the implicit negotiating and bargaining skills discussed previously. For example: Smithdale High School is situated in one of the poorest cities in the state and has a high incidence of adolescent pregnancy and excessive rates of school truancy and dropouts. Violent encounters among students have increased significantly in the past three years. In response, the superintendent of schools created a task force to study the problem and make recommendations that included the social worker assigned to the school. She argued against a proposed program that focused on punishment and instead advocated involving students in problem identification and resolution, arguing that without student involvement, any intervention was unlikely to succeed. Other task force members disagreed. After considerable debate, the task force recommended to the superintendent—and the principal implemented—a discipline-management program of nonnegotiable interventions with students who engaged in violent conflict. Administrators dictated the terms of conflict resolution, and students were expected to comply. The social worker respected the decision but continued to assert her belief that any proposed intervention had to include the voices of students and teachers who were directly affected by the violence.

As is the case with many large bureaucracies where power and decisionmaking is centralized, the worker’s ability to influence the superintendent was limited. As the social worker anticipated, the emphasis on unilateral decisionmaking and punishment led to the program’s failure. The disciplinary initiative taught students about unacceptable activities and behaviors and the consequences for noncompliance, but it did not provide alternative means for dealing with conflict. Teachers were frustrated and ceased to carry out the program. The program’s deficits increased the social worker’s stature, since she had been adamant from the beginning that addressing the problem of student violence required a more nuanced approach. She was asked to chair another task force to explore other alternatives and was given permission to invite the president of the school’s student government to attend to represent her peers’ point of view:

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The worker presented the task force with information on strategies that had been successfully employed in school systems comparable to hers. The task force ultimately selected an evidence-guided program that focused on teachers who would be trained to resolve conflicts in the classroom and incorporate a conflict-resolution curriculum into regular lessons and would be taught group process skills and undertake self-exploration to expand awareness of their own conflict-resolution styles. The task force recognized that the proposed program would involve additional costs that the school system would have to absorb. With the worker’s help, task force members justified the costs by quantifying the costs associated with not adopting the program, costs that included increased sick days for teachers and the staff time required to document the reasons for student suspensions. The social worker also identified possible sources of private funding for the initiative. The worker and selected others from the task force began with presentations to three constituent groups—the school’s principal, the teacher’s union, and the full Student Government Association (SGA) board—and elicited their support. The task force then took its proposal to the superintendent who approved the recommendations and secured private funding for the training program.

The school social worker operated in a setting where administrators and teachers determine the function and roles social workers play. In her efforts to advocate for a violence prevention program that adhered to principles of social justice and reflected the evidence, she capitalized on her skills of mediation and her well-established reputation as an essential member of the educational team. While she continued to assert her viewpoints, she remained respectful of her colleagues, emphasizing that they “were in this together.” Conflict

Low-ranking participants rarely use conflict-oriented strategies when they are addressing organizational problems because of their vulnerability to reprisals. At the same time, certain situations, such as violations of clients’ rights, require more adversarial actions, especially in the face of marked dissent over goals and methods. Before engaging in conflict-oriented strategies, however, practitioners must evaluate possible responses and their own resources. If either their job or personal credibility is at stake, only severe injustices and unethical practices should require such risks and sacrifices. Polite, respectful disobedience can be a highly effective strategy that involves limited risk. The worker holds to a stance of organizational loyalty and concern for client well-being rather than one of moral indignation. For example, a family

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agency required workers to submit confidential data about clients to the state department of social services. After several unsuccessful efforts by a practitioner to have the policy changed, the supervisor demanded that the worker provide confidential client data. The social worker politely refused the request, citing the ethical principle of client confidentiality. The worker also expressed concern about the negative impact on the agency and its reputation, “should the practice become public.” The agency supervisor retreated and renegotiated the arrangement with the department of social services. Had this practitioner responded with hostility, this would likely to have precipitated pushback from the supervisor and representatives of the agency’s hierarchy, and the issue—clients’ right to privacy—would have been lost in the ensuing struggle. Group action can diminish the risk of reprisal for individual workers. Position statements, petitions, and demonstrations are effective methods in dealing with powerful harmful practices and organizational participants. The alliance or coalition must be firmly unified and committed. In undertaking collective action, workers must be sure that each member is publicly committed to the cause in order to avoid finding themselves with a group of “closet advocates” whose barks are ferocious but whose bites are mild. Skillful use of collective action also requires that members decide upon a strategy that ensures that their concerns will be heard. For example, it is unlikely that an agency administrator will respond positively if concerned staff members set upon her all at once. A more effective strategy would be for the group to designate one or two spokespersons to speak on their behalf. Decisions regarding who should serve in this capacity will reflect interpersonal factors, such as already having a good working relationship with the administrator, feeling most comfortable in the role of advocate, holding formal or informal power, having a compelling “story” to share, and the like. Refusing compliance. An action that we might need to take is to refuse to engage in behavior that violates ethical or legal standards. Our refusal should be presented matter-of-factly and include a justification for our actions: “I am sorry, but the client has to be informed about her legal rights and options— professional ethics requires it. I am also concerned about the negative impact upon our department’s reputation if this practice became known.” Implying further action. There will be instances when we may need to inform agency personnel that we intend to take further action if our clients’ needs or requests are not addressed. We must be prepared to follow through with such a warning. Making empty threats is counterproductive, undermines credibility, and is unlikely to succeed. Several actions may be considered, including reporting egregious actions—or inaction—to the appropriate

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licensing boards or legal authorities and contacting the media. In general, the intended action is designed to bring unwanted scrutiny upon an organization or individual or to force adherence to regulatory standards or organizational policy. Using this skill, as well as refusing to engage in a certain behavior, can lead to what is referred to as whistleblowing, which occurs when a worker calls attention to behavior of individuals or organizations that is unethical, illegal, or in some other way unacceptable. The Code of Ethics of the National Association of Social Workers (NASW) specifically requires us to act when we become aware of such behavior. While the skills that we have previously identified might be enough to resolve the problem, we might have to take the riskier step of publicizing egregious individual or organizational behavior. The importance of this activity, as well as its potential risks to the worker, is reflected in NASW’s Legal Defense Fund, which was created in 1972 to assist members with any legal costs associated with defending themselves against retaliation following their engaging in whistleblowing activity (Barsky, 2010). The methods and skills of the engagement phase are presented in Table 15.4. Implementation and Institutionalization

After a desired outcome is adopted, it needs to be put into action, since initial acceptance does not ensure implementation. For the practitioner, much work and frustration may still lie ahead. An adopted change can be negated by a delay in execution. It can be distorted, undermined, or scaled down by executive participants, organizational processes, or the personnel responsible for the change (Brager & Holloway, 2002). Executive staff uncommitted or opposed to the adopted change may interfere with or undermine implementation. They might simply be preoccupied with other issues or pay insufficient attention to necessary follow-up, postpone implementation, or provide inadequate personnel and financial resources. In the implementation phase, informal and formal structures can be used to reduce the stress associated with the change. To maintain administrators’ cooperation, the innovation has to be experienced as being in their self-interest. In an earlier example from this chapter, the worker’s efforts to obtain the school superintendent’s approval to implement a violence prevention program ultimately were successful because the task force that she organized anticipated his concerns about financing the program and found external funding. In addition, he was able to take credit for this innovative program, which enhanced his reputation within the city bureaucracy.

Table 15.4 Engagement Methods and Skills: Organizational Change Select the appropriate engagement method.

• Demonstrating method: Appropriate with problems associated with professional function and program gaps. • Collaborating method: Appropriate in open organizations where goal consensus exists and either equity in resource distribution or presence of close interpersonal relationships. • Persuading method: Appropriate in organizations characterized by goal dissent and disparity of power. • Creating conflict method: Appropriate only in situations where a more extreme form of pressure is required, as in violations of client rights.

Collaborate with colleagues in identifying a problem and finding effective solutions.

• Invite common search for data, possible solutions, and resources.

Persuade colleagues of the problem and solutions.

• Clearly define the problem. • Illustrate the problem’s seriousness with facts, case material, and testimony of colleagues, clients, or both. • Present the case for the effectiveness of the plan for a solution. • Provide evidence for the feasibility and desirability of the proposed solution. • Use a two-sided argument when resistance is anticipated. • Use a one-sided argument when positive response is expected. • Use humor and role-play to deflect resistance. • Use language compatible with the values of the audience. • Arouse anxiety out of concern, loyalty, and identification with the organization. • Propose alternative solutions and involve staff in the process. • Identify an extreme solution and pursue a reasonable compromise. • Engage in cost-benefit analysis.

Engage in conflict to resolve a problem.

• Evaluate potential organization responses and personal/structural resources. • Assume a stance of organizational loyalty rather than moral indignation. • Engage in polite, respectful disobedience. • Reduce individual risk through collective action. • Refuse compliance. • Imply further action.

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After a worker influenced the staff in her health clinic to establish an ad hoc committee to improve the application process for patients to be seen for services, the clinic’s medical director—who oversaw operations in several locations, but whose office was located elsewhere—missed several meetings with the committee, despite having committed to doing so. This reflected his ambivalence about the initiative. The worker came to this conclusion: I realized we hadn’t taken the interests of the medical director into account. I hadn’t considered that he was concerned about keeping his clinics financially viable. The next time he visited our clinic, I asked if we could chat for a few minutes, and he told me that he missed the opportunity to see patients, complaining that all of his time was taken up with “administrative BS.” I empathized with him but used his comments to point out to him how our patients’ health was compromised by the slow wait times. I suggested that his experience as an emergency room doctor would be helpful to us as we tried to figure out how to expedite wait times but keep costs down, and I invited him to our next meeting. This time he came, and we engaged in a productive exchange of ideas. He was receptive to our ideas and promised to work with us to implement them, and he expressed his appreciation for being able to “be involved in medicine again rather than just pushing papers.”

The steering committee was responsive to the director’s interests. His lack of interest decreased, and his involvement and commitment increased. Acquiring and maintaining the commitment of key participants are always essential. Their support provides the context and sets the tone for other participants’ cooperation. The social worker seeks to keep the agreed-on change in people’s minds and on the organizational agenda by assigning specific tasks to participants. If possible, a feedback system is built into the proposal, such as regular progress reports to staff to provide monitoring and accountability. Some organizational structures are incompatible with particular innovations. Even organizational features that promote acceptance of innovation can hinder its implementation. Organizations characterized by low formality, for example, tend to encourage innovation but also tend to hinder its institutionalization. While some structures are too rigid, others are too flexible to support and integrate the innovation. Therefore, even before an adopted change is implemented, the workers attempt to modify existing structures to increase the chance of success. A hospital social worker reflects on a new format for team meetings: As a new format for team meetings was adopted, I realized that the format time could cause frustration. At the first meeting under our new plan, I wondered aloud

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if there would be sufficient time to discuss patients scheduled for presentation since this was to occur at the end of the meeting. Staff agreed to extend rounds another 15 minutes. The staff found the additional time beneficial. It eliminated the potential for stress arising from many agenda items competing for time. Now each would receive sufficient attention.

The staff assigned to carry out an innovation represent another potential obstacle to implementation. Expectations may be unclear, or the staff may unwittingly distort the objective. Participants may lack the necessary knowledge and skills for performing the required tasks. Others may lack sufficient motivation to commit themselves to the new way of doing things, and the additional demands and competing time pressures may overwhelm others. Social workers must be sensitive to the anxiety aroused by changes in role expectations and performance. They must provide a clear explanation of role requirements, incorporating into the implementation the in-service training, consultation, and ongoing support necessary to ensure interest, motivation, and skilled task performance. The worker may consider ways to encourage staff interest in these initiatives, which can include providing food, continuing education units, or giving time off to allow them to participate. Throughout the implementation phase, the worker pays careful attention to task performers and their need for approval and recognition. After a designated time, the implementation is evaluated to determine whether the desired objective is being achieved and whether unexpected negative consequences have appeared. If modifications are needed, they are instituted before the innovation is standardized and formalized. Once an innovation is in place, the worker needs to evaluate the extent to which the original problem that warranted it has been ameliorated. When the change in an organization’s purpose, structure, procedures, or service arrangements is no longer perceived as a change, but rather as an integral part of its ongoing activities, the innovation is institutionalized. To ensure continuity, the worker lodges the innovation with a person who has staying power or enjoys a stable status. In the previous example of a worker’s efforts to improve staff relationships and coordination in a medical setting, she observed: Every six months, team composition changes with rotation of residents. In addition, a new chief resident means that a new personality and work style are introduced. Therefore, I realized that the head nurse is key to maintaining stability, so the structural change [the new format for medical rounds] was lodged with her. She orients

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new team members, including the residents, to the workings of the floor—the routines, procedures, etc.—and will see that the change is continued.

Other linking devices and procedures may be developed to ensure stability, such as inviting new staff to observe existing processes and procedures or preparing a manual to formalize staff responsibilities. Whatever the method, the worker continues to monitor the institutionalization of the innovation. We now turn to legislative advocacy in chapter 16. Our practice will provide ample evidence of the need for changes in existing laws, policies, and regulations that affect our clients, or the introduction of wholly new versions. In that chapter, we identify a number of strategies and skills needed to affect the political, legislative, and regulatory processes.

Influencing Legislation, Regulations,

SIXTEEN

and Electoral Politics

Social work’s commitment to social justice through political activity originated more than a century ago, in the practice of settlement pioneers such as Jane Addams. Contemporary life-modeled practice actively embraces the commitment to a just society through the participation of practitioners in “policy practice” (Weiss, 2016). Policy practice is 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” (Jansson, 2008, p. 2014). When we engage in policy practice, we seek to improve opportunities and resources for those living in poverty, as well as other vulnerable and marginalized populations, by advocating for more effective legislative and regulatory responses to human needs. Consistent with the assumptions that guided the discussions of community practice and organizational influence in chapters 14 and 15, we assert that life-modeled practice always includes policy practice. We are attuned and willing to respond to our clients’ experiences with unresponsive social institutions, falling through the many cracks in the social safety net, overt or covert discrimination, and ongoing marginalization. While some social workers pursue legislative advocacy as a full-time career, all of us will have opportunities to

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advocate for policies at the local, state, national, and international levels to eliminate inequality and promote social justice. Policy practice in social work focuses on the need for changes or reforms in nine arenas (Jansson, 2008): • Right-conferring policies protect people from discrimination (e.g., civil rights laws, grievance procedures within institutions and organizations, workplace discrimination laws, and the Americans with Disabilities Act). • Need-meeting and equity-enhancing policies provide essential economic and health benefits, often targeting especially vulnerable populations (e.g., subsidized housing and day care, Medicaid, and energy assistance). • Opportunity-enhancing policies provide education and training opportunities (e.g., Head Start, affirmative action, and low-interest student loans), to level the playing field. • Public improvement policies benefit all people (e.g., public transportation, highways, and parks). • Public safety policies protect all people (e.g., criminal justice and traffic laws). • Economic development policies promote economic growth (e.g., empowerment zones and small business loans). • Asset accumulation policies mostly assist advantaged citizens, but they also can help the less advantaged (e.g., mortgage tax deduction and the earned income tax credit). • Regulations guide the enactment of public policies and protect the public from corporate, business, and landlord abuses (e.g., pollution, prescription drugs, false advertising, and rent control). • Social services help vulnerable populations with life-transitional and environmental stressors (child welfare, health and mental health, school, and aging).

Policy practice requires knowledge about policy development, legislative and regulatory processes, and electoral politics. In its most basic form, political advocacy includes telephoning, e-mailing, and writing letters to decision-makers and mobilizing others to do the same. In its more complex forms, political advocacy includes lobbying, coalition-building, testifying, demonstrating, rallying public support, and working with the press and other media on behalf of desired legislation. As examples in chapter 14 illustrated, community practice and legislative advocacy often are used in combination to influence policymakers. Political advocacy by social workers consists of the following: 1. Influencing legislative policies by lobbying for or against new statutes and policies, or those being considered for modification. This requires knowledge of the

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legislative process, existing law and policy, and methods and skills to influence policy development. 2. Influencing official regulations that control how statutes and policies are carried out by lobbying the people who write the regulations. This requires knowledge of the regulatory process, existing regulations that bear on the particular concern, and methods and skills used to modify regulations that go beyond statutory authority or the spirit of the law. 3. Influencing the electoral process. This is accomplished through (1) voter registration initiatives that encourage marginalized populations to exercise their right to vote, and (2) involvement in the political campaigns of candidates for elective office who support the advancement of social justice and the issues we care about.

INFLUENCING LEGISLATION The Legislative Process

In the federal government and most states, the legislative process by which a bill becomes a law begins with a legislator introducing it. Therefore, we begin this discussion with a description of the legislative process and the relationship between the legislative and executive branches. States vary in their legislative processes; therefore, social workers must research the process in their particular state. The following website provides a link to a description of every state’s legislative process: http://statescape.com/resources/legislative/legislative-process.aspx. Because the legislative process can be quite complex and extremely time and effort consuming, legislators are selective about which bills they choose to place on the legislative agenda. Important factors that influence legislators’ decision to sponsor a bill include acquiring support from and currying favor with their constituents and donors, gaining media attention, and chances for the bill’s ultimate success. Consistent with the need to develop a cost-benefit analysis, as discussed in chapters 14 and 15, social workers should be able to demonstrate that the costs associated with their policy initiative are outweighed by benefits, in the form of enhanced reputation to lawmakers, reduced costs to taxpayers, and/or others. Introduction of Legislation

Lawmakers often introduce specific legislation at the request of specialized advocacy groups or individual constituents. Therefore, social workers can influence legislation through participation in a special interest group or via their status as

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a legislator’s constituent. Social workers who work for the election or reelection of a particular legislator may have additional influence. There is a wide range of specialized advocacy groups whose interests coincide with social work values, including the American Federation for the Blind (AFB), the National Association for the Advancement of Colored People (NAACP), the American Association of Retired Persons (AARP), the Southern Policy Law Center (SPLC), and the National Alliance for the Mentally Ill (NAMI). The National Association of Social Workers (NASW) is another specialized constituency group that advocates for the interests not only of the social work profession, but also the interests of marginalized groups, and more generally acts to advance social justice. In addition, other advocacy groups represent conservative interests, like the National Rifle Association (NRA) and the Family Research Council (FRC), and environmental issues, like the Environmental Defense Fund (EDF) and the Nature Conservancy. Assignment to a Committee

After a bill is introduced, it is assigned to a committee. Committee members have three options: reject the bill by taking no action, refer the bill to another committee, or refer the bill to a subcommittee for research. If rejected by the subcommittee, the bill dies. If approved, the bill goes back to the full committee for debate and amendment. If rejected by the full committee, the bill dies. If approved by the full committee, the bill is presented for a public hearing. After the public hearing, the committee decides whether to defeat the bill or forward it to the full legislature. Presentation to Legislative Chambers

If the decision is made to move forward, in most states the bill proceeds to the full membership of the lower chamber for further debate and amendment. At the federal level, this chamber is the House of Representatives. Each state has its own name for this body. If rejected by the lower chamber, the bill dies. If approved, it proceeds to the higher chamber, where it undergoes the same process. In the federal government, this is the Senate. States have their own designation for this body. In jurisdictions where there are two legislative bodies, when each body passes different versions of a piece of legislation, the differences must be reconciled, so the bill is forwarded to a conference committee. If the conference committee works out the differences and reaches an agreement, the revised bill

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is forwarded to both chambers. If both chambers accept the revised bill, it is forwarded to the president or governor. Presentation to the President or Governor

If the bill passes both chambers without change in language, it is sent to the president or governor, who has a certain number of days to sign or veto the bill. If the chief executive signs the bill, it becomes law. If, on the other hand, this person vetoes the bill, it may still become law if the legislature overrides the veto usually by a two-thirds vote in both chambers. Every state provides information on the progress of any bill that has been introduced during its legislative session. The federal government also has a website that allows citizens to look up the status of all legislation being considered by Congress (https://www.congress.gov/search?q=%7B%22source%22%3A%22legislation %22%2C%22congress%22%3A116%7D). Social Work Lobbying

Successful social work lobbying requires information-gathering, building an agenda, engaging legislators and other personnel, influencing key players, networking, coalition-building, and testifying. Information-Gathering

Lobbying requires us to ascertain the viewpoints of key officials, including the chief executive and legislators who have influence through their formal positions and also through their informal relationships, connections, and reputations. We also should collect information from other members of government bureaucracy, like legislative staff; review data from public polls; and examine media coverage of issues relevant to our proposed legislation. Staff of legislative committees, staff assistants of key legislators, and lobbyists from NASW or an organization that is associated with the bill’s focus also may be important sources of information and influence. Undertake Substantive and Procedural Research

In influencing the passage, amendment, or defeat of a particular bill, the social worker needs to undertake both substantive research on the contents of the bill and procedural research on its history. Substantive research requires a review

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of existing law that the bill seeks to change, amend, or replace. The worker then crafts a position statement that can be presented to key legislators, which includes the following: 1. An analysis of the modifications or additions to present law as proposed by the bill, including its strengths and weaknesses and new problems that the bill may create. 2. Facts that support or negate key points in the bill. 3. The costs and benefits of implementing the bill, sources of funding, and new positions or structures required to carry out the legislation. This information is usually contained in the financial impact statement prepared by the legislative staff or a relevant governmental agency. 4. Positions held on the bill by relevant governmental agencies and key interest groups, which yield information on points made for and against the bill and suggest potential allies or opponents.

The worker conducts procedural research to determine the bill’s progress through the legislative process in order to determine the following: 1. Which committee originally referred the bill, where it is now, and where it has yet to go. 2. If a similar bill exists in the other chamber of the legislature and, if so, the committees to which the bill has been referred. 3. If the bill has already been amended, and if so, where, when, why, and how this was done. This information gives clues to what in the original bill was objectionable or unworkable and whether the bill has the support of key legislators. 4. Identify the sponsors of the bill and their motivation for introducing it. 5. Review the legislature’s rules of procedures for conducting legislative business.

This information typically can be obtained from committee staff. The social worker also collects information on the committee responsible for the bill’s hearing and its members (DeRigne, Rosenwald, & Naranjo, 2014; Haynes & Mickelson, 2010). Through observing the committee in action or collecting information from staff, the worker becomes familiar with its practices, procedures, and protocols. The worker also should seek to learn about committee members’ backgrounds, constituencies, interests, personal philosophies, political consequences of their vote, party affiliations, voting records on relevant topics, and issues on which they campaigned. Social workers can use this information to construct a committee profile to guide their lobbying efforts and prepare their testimony.

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Develop Strategies to Persuade Decision Makers

After gathering relevant information, social workers develop strategies to persuade important decision-makers to place the issue on the agenda of other decision-makers in the legislative setting. This requires that they create interest and support for their policy initiatives and assess the constraints and opportunities created by the current political, social, economic, and cultural environments. When we engage in political advocacy, we search for and take advantage of windows of opportunity. For example, a dramatic incident of child abuse or neglect, or the death of a homeless person, may raise the public’s awareness and receptivity to a legislative initiative. We can seize that moment to place our legislative initiative on the agenda, as the following example reveals: A student was placed in an inner-city hospital that served a largely indigent population. A passing motorist took cell-phone video of one of the hospital’s patients—an older black woman—being “dumped” at a bus stop by hospital security late on a cold winter night. The patient was dressed only in a hospital gown. The passerby contacted law enforcement as well as the media, and the video went viral. Initially, the city council passed a law that prohibited hospitals in its jurisdiction from engaging in such behavior and attached heavy fines for violations. After the state legislature began its session one month later, a bill was introduced and passed unanimously that prohibited and criminalized actions of this sort.

While one incident may be enough to spark the public’s and legislators’ interest in an issue, the worker must be prepared to provide the more general context, which includes the magnitude of the problem and the availability of existing services and resources to address it. The worker can provide data on the need for the relevant services as expressed by those who have sought or would benefit from them, as well as estimated by experts in the field. Engaging Legislators and Influential Officials

The effectiveness of political advocacy often depends upon the worker’s ability to cultivate personal relationships. From these contacts, the social worker attempts to ascertain the viewpoints and positions of important legislative actors, including chief executives, legislators from the worker’s own and other legislative districts, key members of government bureaucracy, and lobbyists and interest groups (Jansson, 2008).

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Legislators are likely to be influenced by the most active segments of their constituencies, a reflection of the adage, “The squeaky wheel gets the grease.” Interest groups and individuals who have the most influence are those who have cultivated and maintained frequent contact with legislators and provided them with technical and political information. Effective political advocacy also depends upon workers’ reputations, professionalism, and ability to influence the public to support their initiatives. We may be passionate about an issue, but the key to effective legislative advocacy is the ability to present our position in a reasoned and logical way to individuals and constituency groups. Successful legislative advocacy requires that social workers live in the world of is. This means that we understand that legislators are particularly responsive to their political donors. Because we are unlikely to have the financial resources that many political donors have, we rely upon our understanding of the issue and the relationships that we have cultivated inside and outside the legislative body, as well as our ability to articulate our position and mobilize others to adopt it. Whenever possible, the social worker attempts to meet one-on-one with key legislators. Because their time is valuable, workers should anticipate that they would have only a brief time to make their presentation. Preferably, the worker submits a copy of the legislative proposal in advance of the meeting, along with the position statement that the worker is requesting the legislator adopt. The worker must be prepared to speak to what is likely to be legislators’ primary concerns: “Who is for it?” “Who is against it?” “What’s it going to cost?” “What’s in it for us?” and “Does this help or hurt our chances of reelection?” We may have the opportunity to present the merits of our initiative, but realistically, we should anticipate that legislators are likely to follow the recommendation of the committee, vote along party lines, or both. Therefore, we must make the most of the little time we have in a face-to-face meeting and directly address legislators’ key concerns. At the state level, the support of the governor is essential in light of this individual’s veto power. To influence the state executive’s view of the proposed bill, it is wise to engage people close to the governor in arranging an interview to briefly present the proposed bill and provide information on groups that have endorsed the proposal and relevant agencies that support it. Administrators of relevant state agencies can be important sources of support because legislators listen seriously to agencies’ representatives. Agency-requested legislation generally has a significantly better chance of passage than legislation without such a request. If an interview is not possible, a brief letter can be left with the governor’s executive assistant, along with copies of the proposed bill and the social worker’s position on the bill. This information also can be conveyed via e-mail; the

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worker should consider using both methods of communication if an in-person meeting is not possible. Networking

Networking with other social workers is an important strategy when we engage in political advocacy, consistent with the group work principle of power in numbers. Such networks might include practitioners who: live in a legislator’s district, are active in their political party and politics, employed by agencies with legislators on their board, or share our concerns about the particular issue. Networking also involves negotiating with state agencies and other groups that will be affected by a bill in order to gain their support. Because different interest groups may have different interests and priorities, we must be prepared to help them reach a compromise that is satisfactory to all, consistent with the group work skill of pointing out underlying commonalities. Networking also includes establishing working relationships with the legislative staff who serve as the links between their legislator and lobbyists. Our work uniquely positions us to help lawmakers understand the consequences of policies that negatively affect clients and the need for additional policies that protect them and afford them greater opportunities. When we meet with key people, we must capitalize upon our practice wisdom and experience. For example, a social work professor and his students secured a meeting with the staff aides of a U.S. Senator and a member of the House of Representatives. In one case, students discussed with the aides HIV testing and patients’ right to privacy. They described the dilemma of rape victims who are unable to learn whether the rapist was HIV-positive. In protecting the rights of individuals living with AIDS, the rights and well-being of rape victims were jeopardized. The staff aide had not thought about the issue from this perspective. In the other case, students described to the aide their frustration at not being able to find and provide services to infants who may be infected with HIV, and how this lack of services was a strong deterrent to finding and retaining foster parents. Again, the issue was entirely new to this aide. Effective networking strategies include the following: • Gather information to justify the need for a bill’s passage or defeat. • Use the collected information in awareness and educational campaigns directed toward the public, professional groups, and legislators. • Solicit written endorsements from professional groups or prominent individuals and signed petitions from voters.

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• Send news releases to newspapers and organization newsletters. • Offer presentations to groups and organizations on the relevant issues. • Prepare and distribute information through the media.

Networking and political advocacy are increasingly accomplished through social media. Social media has made it much easier to bring attention to a particular issue and mobilize interested citizens to take action. Social workers can join and use online advocacy sites that reflect the profession’s commitment to social justice to initiate or participate in political action. These include https://front.moveon.org/, https://www.answercoalition.org/, and https:// www.change.org/. Social media sites like Facebook and Twitter also have become platforms for individuals to mobilize others to contact and engage in political action (Brady, Young, & McLeod, 2015). For example, the “March for Our Lives” campaign in 2018 was organized largely through social media by students of Marjory Stoneman Douglas High School in Parkland, Florida, following a mass shooting at their school. Organizers used the march to send a message to politicians and spur others to demand that they enact sensible gun control legislation. Protesters have used social media to organize protests following the death of George Floyd. In fact, the viral video that captured his murder at the hands of law enforcement prompted the nation- and worldwide protests that ensued. Workers can coordinate efforts to contact legislators via e-mail or voicemail. Two websites hosted by the federal government simplify this process. Citizens can find their senator using https://www.senate.gov/general/contact_information /senators_cfm.cfm, and using their ZIP code, citizens can locate their representatives at https://www.house.gov/representatives/find-your-representative. Using electronic phone banking, citizens also are able to reach out to a wide range of individuals with an automated message promoting a particular position on a legislative initiative or political candidate. After the election of President Donald Trump in 2016, a group of former Democratic congressional staffers created the Indivisible opposition movement (https://indivisible.org/). They established an online platform to disseminate information about legislative priorities, advertise upcoming political events and rallies, and mobilize citizens to become engaged in the political process, usually in protest of actions by the Trump administration. In addition, they produced a manual for citizens that described how they could become involved in the legislative process and influence their members of Congress (MOCs), which can be found at https://docs.google.com/document/d /1DzOz3Y6D8g_MNXHNMJYAz1b41_cn535aU5UsN7Lj8X8/edit#.

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After the 2018 midterms, when the Democrats regained control of the House of Representatives, Indivisible produced a new guide that explained how citizens could “go on offense” and work with the Democratic majority to resist the Trump agenda and promote more progressive policies (find it at https:// indivisible.org/resource/indivisible-offense-introduction). While the guide is oriented toward a Democratic, progressive agenda, it is relevant in all instances when we attempt to influence MOCs. Coordinated strategies to contact MOCs through e-mail, voicemail, and mailed correspondence appear to have some impact on influencing legislators’ positions (Barberá, Bonneau, Egan, Jost, Nagler, & Tucker, 2014). Legislators are particularly interested in and attend to how many constituents take a position on a particular issue rather than the specifics of the position. This suggests that correspondence should be succinct and clearly state the position and how much support it has. Research also suggests that such action is more effective if it is sustained over time and includes diverse constituency groups (Olzak, Soule, Coddou, & Muñoz, 2016). Social media has made it easy to generate and sign online petitions. However, the proliferation of petitions has actually led to their having a reduced impact on policymakers (McDonald, Nardi, & Tomlinson, 2017). Social workers must recognize the dangers of using or overly relying upon social media as a means of engaging in political advocacy. Its misuse has resulted in the spread of propaganda and “fake news.” However, social media does provide us with a powerful means of influencing large groups of people and mobilizing them to take action (Auger, 2013; Guo & Saxton, 2014). Students in a class of one of the coauthors were tasked with developing and carrying out a strategy to influence MOCs to reauthorize the Violence Against Women Act (VAWA). Signed into law in 1994, the bill established, among other things, the National Domestic Violence Hotline and the Office on Violence Against Women within the U.S. Justice Department. It also provided funding for state and local programs to expand services to victims of violence and provide violence prevention programs, mandated gender-sensitive training for law enforcement and criminal justice personnel, and expanded the legal definitions of violence against women and protections for women who have been victimized. A condition of the original law was that Congress must reauthorize its funding every few years. Because of a government shutdown that occurred in December 2018 and disagreements between the Democratic and Republican parties regarding proposed amendments to the bill, funding for VAWA lapsed. The social work students decided upon a strategy that capitalized on their many social media contacts. Using Facebook and Twitter, they sent out information about the bill and its importance and included links to the blog of the National

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Coalition Against Domestic Violence (NCADV), which provided additional information about the bill and how citizens could get involved. Students also included the links provided earlier in this chapter on how to contact MOCs. The students recruited fellow social work students, colleagues at their field practicum, and faculty to contact their representatives and senators, providing them with the same information on the bill, the NCADV’s blog, and how to contact MOCs.1 Coalition-Building

Coalitions in the political arena are formed for a limited purpose and are usually temporary; they include organizations and groups that share a common perspective on a legislative issue. When a coalition achieves its objective, the members may decide to dissolve it or to take advantage of the linkages that were developed and build a new coalition to address a new issue. Coalitions of organizations and social workers, other professionals, and interested community members and citizens are more successful at influencing legislation and policymaking when they work together rather than separately, when they must compete for legislators’ time and attention. Competition among agencies for limited resources is apt to be ineffective and lead to interagency conflict. Therefore, coalitions of human and social service personnel designed to influence legislation have grown in number and size in response to severe cuts in services and programs sorely needed by vulnerable families and individuals. Agencies and other groups that decide to band together can benefit from pooling their resources and working cooperatively to educate and influence political decision-makers. A broad-based, unified voice is more apt to be heard than the cacophony of competing voices. If an issue is narrowly defined, organizations with conflicting interests are more willing to overlook their differences and form a coalition in order to have a more powerful impact. Further, if an issue is wide in scope, it is more likely to highlight differences that may reinforce self-interest and discourage organizational cooperation. For example, a coalition of social service programs and neighborhood groups and retail associations supported a bill introduced in one state’s legislature that would provide more money for programs for the homeless. The members all had different perspectives. The social service programs wanted to provide more comprehensive services to a particularly marginalized population. Neighborhood groups desired to rid their communities of “undesirable” homeless individuals, while groups that represented local merchants supported the measure because retailers believed that homeless individuals prevented customers from frequenting their places of business.

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Hearings, Preparing Testimony, and Testifying

Jansson (2008) suggests that the chances to pass legislation are much greater if powerful politicians with an array of perspectives sponsor it than if the proposed legislation lacks such support. Multiple sponsors make the proposed legislation more visible and increase the likelihood that the bill will overcome legislative obstacles. They can press for a hearing, make necessary compromises and tradeoffs to move the bill out of committee, push to get it scheduled by the rules committee, get it out of the rules committee and onto the floor of the legislature, and apply pressure to get it passed by both houses of Congress. Committee chairs and committee members whose expertise is recognized by their peers are influential. When a bill touches on a concern of a legislator’s constituency, that person is likely to actively sponsor it. Therefore, during the fact-finding phase, we should consider how our proposed legislative initiative would affect lawmakers’ constituents, as well as their views on the proposed legislation. We also should ascertain lawmakers’ electoral margins, since those who won by large margins and are widely popular with their constituents are more likely to be responsive to interest groups and to support more unpopular causes because they are less worried about their reelection chances. Hearings draw media and public attention to a proposed bill, although they also run the risk of expanding public opposition and may have unintended consequences. Readers will remember the illustration presented in chapter 14, in which social workers brought a group of homeless individuals to the state capitol to advocate for the passage of legislation that provided this population with more services. The social workers arranged for a strong media presence and for selected homeless individuals to give testimony. The interview with one young, African American homeless mother may have lent a sympathetic face to the problem, but the social work student believed that the interview exploited the client’s pain and may have reinforced negative stereotypes about homeless individuals. When we engage in legislative advocacy, we want to take advantage of hearings that are open to the public. Working alone or with others, the social worker arranges for testimony on behalf of the bill by expert witnesses, especially staff members of relevant governmental agencies. Depending on the nature of the bill, former or potential clients, practitioners, community leaders, representatives of special interest groups, and independent professionals can also be effective. Presentations based upon the substantive research described previously, which include relevant case vignettes, are particularly persuasive.

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Prior to the hearing, social workers develop written testimony based upon their substantive and procedural research. Written testimony should not be read, but rather spoken from an outline so that the person can maintain eye contact with committee members and sustain their interest. Our testimony should briefly discuss the issue addressed by the bill and our position on it. We must be clear about what the bill will and will not accomplish, giving as objective a description as possible. Because lawmakers may be unfamiliar with the issues, we must avoid professional jargon, and as we have repeatedly noted, our testimony should be based upon facts, not values and “shoulds and shouldn’ts.” The social worker must be prepared to answer questions from the committee and to furnish additional information and comments on particular points of the bill. Copies of the position paper and the written testimony should be distributed to committee members beforehand, and copies should also be available at the hearing. An Illustration of Influencing Legislation

A myriad of federal and state laws address the problem of child sexual abuse (CSA). Much of the legislation focuses on mandated reporting requirements and criminal statutes for perpetrators, but legislation designed to prevent CSA also is needed. The process by which a piece of legislation called “Erin’s Law” came into existence is illustrative of the impact that one social worker can have (Anderson, 2014). Erin Merryn was a young social worker who herself had been sexually abused multiple times as a child. She disclosed her abuse in 1998 at age 13, and by 2004, she began speaking publicly and writing about her own experience to draw attention to the need for legislation to prevent CSA. Information-Gathering

The first step Erin chose, as a political advocate, was to investigate current federal and state legislation to determine what laws (if any) already addressed the prevention of CSA. No such laws existed, either at the federal level or in Illinois, the state in which she lived. Erin’s research revealed that in most cases, including in her state, prevention was presumed to occur through laws that required convicted individuals to register as sex offenders and laws that required a jurisdiction to notify a community if a registered sex offender resided in it. Erin examined the literature on the impact that registries had on reducing the incidence of CSA, as well as the factors that contributed to children

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being victimized but remaining silent. Her research led to the following evidence-based conclusions: 1. Sex offender registries were ineffective at preventing CSA. 2. Most children are reluctant to reveal their sexual abuse while it is occurring. 3. School-based prevention programs had been found to be effective at preventing CSA by teaching children how to protect themselves, identifying for children what to do if they are abused, encouraging children to talk to people who are “safe” for them if they are uncomfortable, and educating school personnel on the signs and symptoms of CSA. 4. Despite the generally positive findings about school-based prevention programs, few states had enacted legislation that mandated them. Also, there was criticism of these programs stemming from the mistaken belief that children would be harmed and unduly traumatized by the program’s content, as well as some parents’ concerns that the school was taking over their role as parents. Engaging Legislators and Networking

Armed with this information, Erin wrote letters to all Illinois state senators in 2010, in which she outlined the problem and the evidence-based solution: legislation that would require all public schools in the state to provide CSA prevention programs for students. She continued to speak publicly throughout the state about her own experience and her fight to enact CSA prevention legislation. This resulted in her establishing a broad network of private citizens and employees of public and private social welfare organizations who supported her initiative and provided her with opportunities to expand her base of support. For example, Erin spoke at an event that led one attendee, the chief of police in a local jurisdiction, to introduce her to another attendee, one of the state senators whom she had previously contacted. Hearings, Preparing Testimony, and Testifying

In response to Erin’s letters and her personal contact with the state senator, legislation was drafted that required Illinois public schools to implement CSA prevention programs. Erin’s very public crusade and her compelling personal story and evidence-based proposal resulted in broad public support for the proposed legislation. This included a large contingent of parents. Therefore, when the legislation was introduced during the 2010 legislative session, it received overwhelming bipartisan support in the Illinois Senate and House of Representatives.

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In May 2010, the bill was passed unanimously in both houses and was signed into law in February 2011 by the Illinois governor. Understanding and Using the Political Context

In 2010, the state of Illinois faced an unprecedented budget deficit of more than $13 billion. A number of programs for children and families were being considered for major cuts, as was school funding. Yet, Erin’s Law received unanimous support and was signed into law, as the first such law in the nation. How could that be? In addition to Erin’s success at lobbying and networking, four factors contributed to the law’s passage: 1. There was increased public awareness and media coverage of the problem of CSA throughout the nation which led lawmakers and citizens alike to want to do something about it. 2. Therefore, it was hard for legislators to not support this legislation. 3. Given the looming cuts to other children’s programs and school funding, legislators could use their support for the law to demonstrate their commitment to children despite the cuts. 4. The law required prevention programs in schools, but it did not authorize funding for their implementation. Local jurisdictions were responsible for finding the funds to implement the programs.

Despite the fact that the law did not mandate a funding stream for CSA prevention programs, it set a precedent that, as of this writing, has resulted in the passage of similar laws in 35 states, while the remaining 15 states are considering similar legislation. The lack of linked funding means that the quality and nature of school-based CSA prevention programs varies widely in local jurisdictions charged with implementing them. Readers may question the value of a law that has no “teeth.” When we live in the world of is, we realize that legislative change occurs incrementally. Had Erin—and, subsequently, advocates in other states—pushed for both passage of the law and funding, it is unlikely that it would have been passed. Maintaining Pressure and Continued Lobbying

Now that most states have put into place laws that require CSA prevention in schools, the local jurisdictions themselves, as well as children’s advocates

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nationwide, have begun lobbying for stable and ongoing sources of funding. These lobbying efforts are being led by coalitions of educators, parents, service providers, private citizens, and public and private organizations. Erin herself is leading an effort to secure federal funding for local jurisdictions to implement the prevention programs. In 2015, with the support of advocacy groups like the National Alliance for Children (NAC), Prevent Child Abuse America (PCAA), and Rape, Abuse, and Incest Information Network (RAINN), Erin was able to secure bipartisan support from U.S. senators, and the Helping Schools Protect our Children Act was introduced. As of this writing, the bill has yet to be passed, but efforts are ongoing and persistent. Many of these efforts depend upon social media and technology. Erin maintains a website, http://www.erinslaw.org/, that provides, among other things, links to citizens’ state and federal legislators and provides talking points for advocates to use in their appeals to lawmakers. Table 16.1 identifies political advocacy skills.

THE REGULATORY PROCESS Regulatory Context

All publicly and privately funded programs that provide services and programs to individuals—ranging from hospitals, prisons, and schools, to family service agencies and everything in between—exist within a regulatory context. Regulations serve to clarify how organizations are to operate programs that fall within the purview of the statutes that created them. Regulations reflect the intent and goals of legislation and ensure that an organization’s policies and programs conform to the legislation that authorized it in the first place. They also serve to protect consumers of an organization’s services and introduce some measure of quality control to ensure that consumers or recipients of services receive equitable treatment. After passage of a law that establishes a particular service or program, proposed regulations are announced in the Federal Register (or, in the case of a state statute, in a state register) prior to implementation. This is followed by a time for public comment, usually through open hearings. Following the comment period, feedback and input are analyzed, which may result in changes in the regulations. Final versions of the regulations are then adopted and published. Regulations often reflect a combination of federal, state, and at times local standards. For example, the federal government established basic regulations

Table 16.1 Political Advocacy Skills Gather substantive information.

• Review existing laws. • Study the strengths and weaknesses of the proposed bill. • Learn facts that support or negate key points. • Study implementation costs. • Research positions held on the bill by key actors.

Gather procedural information.

Review the committee route for the bill. Explore the current status of the bill. Assess the bill’s sponsors and their interests. Learn the legislature’s rules and procedures.

Engage legislators and influential officials,

Study each legislator’s background (voting record, constituencies, and interests). Develop personal relationships. Maintain frequent contacts. Develop and maintain contacts with persons close to the chief executive (governor, president). Gain the support of administrators of relevant state agencies.

Develop networks.

Find others to support the bill (social work politicians, social workers living in a legislator’s district). Clear the bill with other groups. Find people to bear witness regarding the need for the legislation. Send out newsletters and legislative alerts.

Build coalitions.

Join organizational and personnel resources.

Preparing testimony and testifying.

Seek multiple legislative sponsors

Educate and influence political decision-makers. Seek the support of the majority party. Seek the support of influential legislators. Use the amending process for promoting a favorable outcome. Engage media and public attention for the topic. Use a written statement to organize testimony, but maintain eye contact with audience. Avoid professional jargon. Provide legislators with the written statement beforehand.

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to govern major social welfare programs like Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), and Medicaid. However, state governments have leeway to broaden—or at times restrict—the scope and operation of these programs, resulting in additional regulations to which state agencies overseeing these programs must adhere. Private associations and groups also have regulatory power over organizations that are in a common domain. For example, the Council on Social Work Education (CSWE) accredits social work programs throughout the United States and has established curriculum standards that all member programs must meet. Students who graduate from a social work program that is not a member of CSWE and is not accredited may have a degree in social work, but they will be unable to be licensed as social workers because licensing laws require graduation from an accredited program. In the human service arena, important regulatory bodies include the following: 1. Joint Commission on Accreditation of Health Care Organizations (JCAHO), for a wide range of medical, health, addiction, behavioral health, and nursing care facilities 2. Commission on Rehabilitation Facilities (CARF), for a range of residential facilities that serve aged, substance abusing, and disabled individuals 3. Commission on Accreditation (COA), for child welfare, behavioral health, and social service organizations

In some cases, organizations may join an accrediting body to enhance their reputation and status, while in others, they must be members in order to provide their services to the public. Regulations evolve over time in response to changing circumstances, including the economic and political context and information gleaned from enactment of the original legislation and its accompanying regulations. For example, since 1937, the federal government has made the possession or distribution of marijuana illegal (Rolles, 2018). However, in response to the public’s changing views of marijuana, and in the face of mounting evidence that supports its medicinal use, many states have legalized the drug despite the fact that federal law still considers marijuana a controlled—and therefore illegal—substance. The legalization of marijuana continues to evolve, which has resulted in evolving regulations. Initially, the legal use of marijuana was available only to individuals with certain medical conditions and required a prescription. Over time, many states have passed legislation that legalizes the recreational use of

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marijuana, which led to further modifications in regulations. States now regulate who can sell the drug—many states require that a specific percentage of businesses selling marijuana products must be minority-owned—and who can buy it. In some states, a prescription is still required; in others, buyers must prove they are residents of the state; and in still others, the only requirement is that the individual be an adult. Challenges within the regulatory process that may require social workers’ intervention include the following: 1. Regulations that are too complicated, confusing, or contradictory 2. Regulations that have become outdated or are unresponsive to the constituents that they are to protect or serve 3. Regulations that allow too much or too little interpretation 4. The absence of regulations that result in inequitable treatment or exploitation of constituents

As an example of the final three possibilities, the United States has been in the midst of an opioid epidemic since the early 2000s, resulting in thousands of individuals dying of drug overdoses or becoming addicted to pain medication, as well as a surge in the manufacture and distribution of street drugs (Gordon & Snyder, 2017). A major contributing factor to the creation and maintenance of the problem has been lax regulations regarding to whom, for how long, and for what conditions opioids like fentanyl and oxycodone could be prescribed. In the face of this crisis, lawmakers at the state and federal levels have been working to tighten these regulations, as well as develop new ones that protect citizens who need these drugs for legitimate medical conditions like chronic pain and pain associated with cancer. The experience of a social work student placed in a public high school reflects the challenges associated with regulations that are confusing and open to too much interpretation. Micah and his field instructor attended a meeting in which the individualized educational plan (IEP) for his client, a 16-year-old transgender youth, was discussed. The student’s father, the vice principal, a guidance counselor, and several teachers also were members of the student’s IEP team. Noticeably absent, however, was the student. When Micah inquired about this, he was told that the regulations governing IEP meetings specified that a parent must attend, but they did not require the student to do so. Micah was puzzled about why his adolescent client could not participate in his own IEP meeting, but he was also concerned because the father prohibited the team and all school personnel from talking with the client about his

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recent acknowledgment of his transgender status. The IEP team believed that the regulations gave the parent the power to dictate what school personnel— including social workers—could and could not talk about with the student, despite their disagreement with his position. We turn to this case later in this chapter to illustrate how social workers can intervene and affect change in the regulatory process. Influencing the Regulatory Process

As in the legislative context, social workers gain influence in the regulatory field through effective lobbying for or against particular regulations. The steps that must be taken parallel those that we use when we engage in legislative advocacy. Analyzing Regulations

Social workers must understand the legislative act that created the regulations in the first place. This requires analysis of the extent to which proposed regulations accurately and fully reflect the intent of the law and the likely impact that they will have on clients. In the case of existing regulations, the worker assesses their impact, considering the four issues previously noted in this chapter. This may lead the worker to identify unintended consequences, loopholes, or gaps in the regulations, as well as aspects that are confusing, outdated, or no longer relevant. Strategies that have been previously identified, including networking, building coalitions, contacting lawmakers, and developing a position statement, will come into play. The intent may require a change in the law that created the regulations in the first place, or modification of the regulations themselves. Organizing Hearings

The initial comment period for proposed regulations is an opportunity for social workers to influence the scope and type of the final guidelines. Social work administrators and supervisors, for example, must understand a regulation’s likely impact on the services that their organizations provide. A carefully drafted written response or a well-structured presentation at a public hearing could be influential. A successful coalition of like-minded individuals and associated organizations can increase the number of people who write comments or provide testimony at the hearing. Hearings are formal settings, which require a more structured response than a simple written comment. Suggested steps that social workers may take,

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whether they are representing their individual viewpoint or the perspective of their agency, include the following: • • • •

Identifying themselves and explaining their interest in the matter Explaining the regulation’s impact on constituents that they represent or serve Providing the reasons for their conclusions Recognizing the legitimacy of other views, but refuting them by providing supporting data • Providing clear documentation (data and case examples) that support their position

Prehearing and Posthearing Activities

Activities both before and after a hearing can help to connect our analysis to the written comments or to testimony provided at the hearing. They emphasize mutual education, information-sharing, and constituency-building to strengthen communication between the administrative authority that will be responsible for implementing the regulations and the social workers who have provided input during and have a stake in the process. Both parties have an interest in the potential impact of the regulation; that fact can be used to facilitate negotiations on points of difference. Prehearing activities include the following: • Learning about the administrative authority’s structure, decision-making hierarchy, jurisdiction, and policy statements • Becoming acquainted with the staff of the administrative authority to identify sources of support or opposition and those with expert knowledge in the relevant area • Sharing our views so others will understand our professional interests and the extent to which they reflect those of other social workers, service providers, and administrators • Researching the administrative authority’s position in order to predict potential decisions and to identify interest groups that seem to dominate agency decision-making

Activities following participation in the hearings include the following: • Maintaining communications with other affected and interested service providers, constituents and clients, and sympathetic staff of the administrative authority

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• Monitoring the relevant regulations and any subsequent hearings for actual or potential implementation problems • Sharing relevant new information with colleagues and any interested parties and gather support if needed • Standing ready to organize service providers to mobilize against a proposed or final regulation

The philosophy underlying these prehearing and posthearing activities is congruent with the emphasis in life-modeled practice on the exchanges between people and their environment and its efforts to improve the level of fit. Our clients use numerous services that are regulated at the local, state, and federal levels. We must pay attention to the ways in which the policies that dictate how services are provided and who can receive them promote—or undermine— social justice. Table 16.2 summarizes the tasks associated with influencing regulatory processes. Practice Example

Previously, we described Micah’s concerns about why his client, a transgender high school student, was not included as a member of his IEP team. The student and his field instructor also questioned how they should handle the father’s mandate that school personnel not discuss his child’s transgender status.2 Before they could do anything about this situation, the social workers needed to understand the regulations that governed the IEP process. Engaging in Research

Micah began his research by looking at the origin of IEPs: the Individuals with Disabilities Education Act (IDEA), which was first enacted in 1973 and amended periodically since that time. State law can mandate more protection for students than IDEA, but not less. States also can apply different criteria to establish guidelines for implementing programs for students who qualify for special education assistance. In addition to specific educational personnel, federal regulations require a parent be a part of a student’s IEP. The state regulations regarding the IEP team that governed the transgender student’s situation mirrored federal guidelines: a parent must be a member of the team, and the student may be a member but doesn’t have to be. After doing some additional investigating online, including reading applicable federal guidelines, Micah discovered that in many states, students were

Table 16.2 Influencing Regulatory Process Analyzing regulations

• Current regulations are too confusing, outdated, or unresponsive, or they allow too much or too little interpretation. • Absence of regulations leads to inequities and exploitation of constituents. • Proposed regulations are consistent with legislation that established them.

Preparing for the hearing • Explain our interest in the issue. • Substantiate the impact of the regulation on constituents. • Provide reasons for our conclusions. • Recognize legitimacy of other views, but refute them with supportive data. • Provide clear documentation. Prehearing and posthearing activities

• Mutual education, information sharing, building constituencies Prehearing: • Learn about the administrative authority’s structure, decision-making hierarchy, jurisdiction, and policy statements. • Become acquainted with the staff of the administrative authority to identify sources of support or opposition and those with expert knowledge in the relevant area. • Share our views so others will understand our professional interests and the extent to which they reflect those of other social workers, service providers, and administrators. • Research the administrative authority’s position to predict potential decisions and to identify interest groups that influence agency decision-making. Posthearing: • Maintain communication with other affected and interested service providers, constituents and clients, and sympathetic staff of the administrative authority. • Monitor the relevant regulations and any subsequent hearings for actual or potential implementation problems. • Share relevant new information with colleagues and any interested parties and gather support if needed. • Remain ready to organize service providers to mobilize against a proposed or final regulation.

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included in the meeting if they were older than age 8 and that, upon turning 16, were considered members of the team by default. The federal government assumed that the parent would be the “voice of the child,” but in many states, once the child reached a certain age (the age varied by state), students were presumed to be able to advocate for themselves. Micah also noted that the language of federal regulations regarding the IEP team had changed from the student being a team member “if appropriate” to “whenever appropriate.” Networking and Coalition-Building

Micah and his field instructor presented the information they had found to the members of his client’s team (excluding the child’s father) and suggested that federal language could readily be interpreted to mean that the transgender student should be a member of the team. The team expressed surprise, as members’ understanding was that students were not to be included. The new information led them to realize that this reflected “just the way things have been done” in their jurisdiction rather than any specific regulation. All members of the team agreed that all the other IEP teams in their school must be made aware of this new information because in the past, many members had questioned why their high school students were not included in IEP team meetings. Micah and his field instructor coordinated this effort, which resulted in consensus being reached among the educational personnel at this one high school that their students should be part of the team, consistent with federal guidelines. With the workers’ encouragement, personnel at their school agreed to contact their counterparts at other schools in the jurisdiction to inform them of this new information and assess their willingness to work collaboratively to bring a proposed change in state regulations to the state’s superintendent and board of education. Micah and his field instructor also contacted their peers at other schools, as well as the administrator who oversaw school social work services for the entire jurisdiction, providing them with the new information and requesting their support. This networking led to overwhelming consensus at all bureaucratic levels within this one school jurisdiction that a clarification of state guidelines was needed regarding student participation. An ad hoc group of personnel in this jurisdiction was tasked with contacting their counterparts in the other 21 jurisdictions in the state to ascertain their willingness to work on a proposal. The intent was to have support from each jurisdiction in the state.

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While personnel from some jurisdictions were less enthusiastic than others—largely due to their concerns about workload—a representative coalition of educators, social workers, and administrators from throughout the state was created. The coalition identified four tasks that should be addressed through subcommittees: 1. Solicit the input of parents throughout the state about the proposed change in regulations governing IEP team meetings. 2. Solicit the input of students throughout the state about including them as members of their IEP meetings. 3. Draft proposed changes in the regulations that required high school students (i.e., ninth grade and above) be members of the IEP team. 4. Develop criteria that would be added to the regulations to identify circumstances under which students should not be expected to participate. Persuading Key Individuals

Micah learned that the regulations governing the composition of an IEP team were established by the state’s board of education following federal guidelines. Changing these regulations did not require a change in state law; the state’s department of education had the power to do this. The members of the state board of education, appointed by the governor, were responsible for setting and implementing policy. In addition, the state board was responsible for appointing the state superintendent to a four-year term, and the superintendent also held a seat on the board. While the superintendent was always an educator, this was not a requirement for other board members. Once the initial task force finished its work, the broader coalition of school personnel agreed upon the language to modify the IEP regulations to include high school students. A new task force, which included Micah’s field instructor (but not Micah, who had graduated from the social work program by that time), was created that was responsible for reaching out to individual school board members. The task force also targeted parents’ groups and public and private advocacy organizations that served the interests of special needs children and their parents. The intent of these actions was to make key individuals aware of the regulatory changes that were to be proposed and, in the case of the organizations, to introduce the changes in the regulations. (State law prohibited individuals from making formal presentations to individual board members.)

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Making a Presentation at a Public Hearing

As of this writing, the proposed regulation has yet to be presented to the full board. The state board of education holds monthly board meetings that are open to the public; the agenda is established months in advance. The coalition of parents, educators, and advocacy groups are working on getting the proposed regulations on the agenda. In the meantime, they are “getting their ducks in a row” by doing the following: 1. Finalizing prepared testimony 2. Systematically investigating others states’ requirements regarding student participation on the IEP team 3. Identifying individuals who can provide expert testimony and parents and students who can attest to the benefit of student membership on the team 4. Crafting responses to any criticism that might surface

ELECTORAL POLITICS Work in Political Campaigns

Many social workers serve as volunteers or paid organizers in the political campaigns of candidates whom they favor, or whom NASW supports by raising and contributing campaign funds through Political Action for Candidate Election (PACE), the political advocacy arm of NASW. Information about this initiative may be found at https://www.socialworkers.org/Advocacy/PACE. Whether social workers occupy formal or informal leadership roles in a campaign, they can make a unique contribution in two ways. First, their understanding of social issues places them in an ideal position to sensitize politicians and their staff to the need to address social and economic inequality. Second, by using group work techniques, team-building exercises, and networking, social workers can build and maintain morale by helping campaign staff and volunteers coordinate their work and providing them with support and encouragement. These activities help campaign staff avoid common campaign problems of competitiveness and conflict. Social Workers in Electoral Politics

An increasing number of social workers are being elected to public office themselves. NASW provides an updated list of social workers currently serving in

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elected positions at the federal, state, and local levels at https://www.socialworkers .org/Advocacy/Political-Action-for-Candidate-Election-PACE/Social-Workers -in-State-and-Local-Office. Other social workers are elected to county/borough or city/municipal offices, as well as to school boards. Others serve as staff assistants or as consultants to state legislators or MOCs, and still others fill appointed positions that wield political power, such as commissioners or directors of local, state, or federal agencies. Maintaining Our Professional Commitment to Social Justice through Political Engagement

Increasingly, social workers are participating in political activity, and social agencies are employing social work policy advocates, who are committed to working politically to improve the quality of life of the populations they serve. Yet given the many professional responsibilities that we already have, it can be difficult to find the time and energy required to engage in political advocacy. As we have noted at various points throughout this book, we must choose our battles; we must decide which issues we are passionate about and then find the time to pursue them using the thoughtful and purposeful strategies described in this chapter. The social work profession has continued to evolve as it responds to traditional and new client needs, knowledge, and skills, and has incorporated new aspirations and goals to meet new social and cultural conditions. Our direct work with individuals, families, groups, and communities must be connected to advocacy and the political process. We are committed to helping the poor and oppressed. This is particularly necessary given the current conservative political climate and the ever-widening gap between the haves and have-nots. We serve the chronically mentally ill, the abused and misused, the homeless, those living with AIDS and other chronic (and often stigmatizing) conditions, newly arrived immigrants and refugees, poor people in hospital emergency rooms and rural clinics, frail and poor elderly people living alone or in institutions, tenants in public housing, children in inner-city schools and their parents, the chronically physically ill, the physically challenged and their families, prisoners, parolees, and probationers. If we are truly going to meet the needs of our clients, we must consider political activism as an integral part of our professional practice. The profession has always shown the courage and the will to move in new ways in response to social problems and societal failures. We believe that life-modeled practice, through its values and principles derived from the ecological perspective, is well

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suited to the social conditions of today’s world. Life-modeled practice seeks to elevate the fit between people’s needs and their environmental resources. In mediating the exchanges between people and their environments, social workers bear witness to social inequalities and injustice, mobilize resources to improve communities, influence unresponsive organizations to develop responsive policies and services, and influence the passage of local, state, and federal legislation and regulations to support social justice. 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. It will continue its 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 chapter concludes the journey that readers and the coauthors have taken together through the realms of life-modeled practice. We believe that the evolving nature of life-modeled practice, with its openness to new theories, makes it especially suitable for understanding and helping people as they confront new and old life stressors generated by new and emerging social conditions and increasingly difficult national and global issues.

Individual, Family, and

Appendix A

Group Assessments

INDIVIDUAL ASSESSMENT: MRS. ROSS

Background data. Mrs. Ross, a 65-year-old Catholic of Italian and Scottish descent, was receiving daily homemaker services. A Medicaid patient, she was also periodically visited by a public health nurse. Because of Mrs. Ross’s increasing withdrawal and apathy, and with her consent, the nurse called the senior service division of a family agency to request social work services. After three home visits, the social worker (a first-year student) prepared a tentative formal assessment for a case conference: Mrs. Ross had accepted the offer of service and supplied her background. Her mother died when Mrs. Ross was four months old, and her father placed her in a Catholic institution, where she lived until her adoption at age 6. She remembers her adoptive mother as loving and compassionate, but she died six years later after a long illness. A year later, her adoptive father married a young woman four years older than Mrs. Ross. At age 17, Mrs. Ross was engaged to a man who burned to death in a car accident. A year later, she married a man who was a “gentleman” until the day of their wedding, when he turned into a monster overnight. Several years

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into the marriage, a son, Jack, was born, and five years later, a daughter, Janice, was born. Her husband beat Mrs. Ross almost daily, and he also beat both children. When Jack was 12, Mrs. Ross found Jack with a shotgun; he said he was going to kill his father. She took the children and walked out of the marriage. She moved to another town and worked at two jobs to support herself and the children. Some 20 years ago, she married a “good man.” Six months later, he died of a heart attack, and since then she has lived alone. Her daughter is married and lives across the country, and they occasionally speak by telephone. Her son lived a few blocks away from his mother, with his wife and two children, and he visited often. Six months ago, he was hospitalized for minor surgery, suffered a stroke, and died. Mrs. Ross did not visit him in the hospital, nor did she attend his funeral, as she had no way to travel. She loves his two children, but she never felt close to her son’s wife and was uncomfortable whenever she visited their home. Mrs. Ross developed Crohn’s disease, a painful, debilitating intestinal disorder, 15 years ago. She had to stop working and has since been housebound.

SOCIAL WORK STUDENT’S REPORT 1. Definition of Life Stressors

Initially, Mrs. Ross requested help with emotionally charged life issues. “Losing my son, Jack, is the latest and most dreadful of the losses in my life. When he died, I couldn’t stand the pain. I wanted to say the hell with it all, but five months later, I’m still alive and the pain is still unbearable. I just can’t handle it on my own anymore.” Mrs. Ross and I agreed on 12 weekly home visits, framed by my impending departure from the agency and the agency’s waiting list. During three home visits, other painful life issues emerged. Clearly, some are interrelated and unresolved earlier transitions and losses reactivated by the son’s death. All are now intensified by Mrs. Ross’s worsening physical condition, her grief, and her social and emotional isolation. Her increasing disability and dependency are additional current stressors. Her loneliness is connected to the great geographic distance between her and her daughter, to her dislike of her daughter-in-law (despite the latter’s frequent invitations to Mrs. Ross to visit her and her grandchildren), and to the lack of friends. Another stressor is living on the second floor and being unable to negotiate two flights of stairs. She cannot leave the apartment by herself; the ambulette attendants who drive her to medical appointments carry her down. Mrs. Ross says that she cannot afford a move to the ground floor.

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Mrs. Ross needs and wants help in coping with these difficult life issues and her feelings of depression and helplessness. 2. Client Expectations of the Agency and Worker.

Mrs. Ross expects me to provide her an opportunity to talk about her life losses and her suffering. Because she is not used to sharing and exposing her innermost thoughts and feelings, she will be sensitive to my reactions. 3. Client’s Strengths and Limitations,

When Mrs. Ross’s life situation was presented to the agency’s utilization review committee, several members suggested that Mrs. Ross is quite disturbed and deals in a pathological way with her stress (e.g., not getting up from her bed for three months). I believe that this assumption ignores the magnitude of her losses, gives insufficient attention to the physical disability caused by Crohn’s disease as well as severe arthritis that she also suffers with, and underrates Mrs. Ross’s strengths and her coping efforts. Strengths. Mrs. Ross demonstrates numerous strengths in coping with her losses. Her religious faith is a major strength. She finds comfort in prayer and in her belief in a life hereafter. Her God is close and personal, and she often talks to God. Several times since Jack’s death, religious beliefs have deterred suicidal thoughts in her: “It would come into my mind that I didn’t want to live anymore, but I couldn’t do that—it is a sin.” Her sense of humor is another strength. After Jack’s death, in despair, she questioned the meaning of life. She called her church and asked to talk to a priest. When she was told, “Sorry, but they are all at bingo,” she was able to laugh at life’s ironies. She also finds pleasure in small things, so that in the midst of her grief, she still enjoys looking at flowers or reading a letter from an overseas relative. Mrs. Ross remembers her mother telling her to “stand straight and hold your head high.” Mrs. Ross has lived by her interpretation of this message: “I rely on myself and keep going, no matter what happens to me.” Her courage, self-reliance, and ability to blunt emotional pain have sustained Mrs. Ross through many traumatic life events and have supported her through physical pain and emotional suffering. She is a survivor, finding ways and reasons to go on with the tasks of living. She deals competently with various organizations and bureaucracies, initiating contacts as needed and following through on commitments. Limitations. Self-reliance seems to mean self-control to Mrs. Ross. As she speaks of her losses, she conceals the hurt and buries the pain. The emphasis on

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self-reliance may have cost her dearly in the past in terms of poor health, and currently in terms of isolation from her son’s family. Inhibiting the grieving process, while it may help her to survive, seems to be a maladaptive coping pattern. Her stoicism in the face of trauma may be related to the belief that traumatic events are expressions of God’s will. Mrs. Ross’s increasing immobility poses another serious limitation. 4. Environmental Supports and Obstacles

Her social and physical environments have profound effects on Mrs. Ross’s functioning. Social environment. Mrs. Ross’s contacts with complex organizations are generally favorable. Representatives from Social Security and Medicare are responsive to her needs. She has experienced little difficulty in maintaining daily homemaker services and the attention and responsiveness of healthcare systems, especially the public health nurses. In contrast, her informal network is severely depleted. She was accustomed to contacts with friends, but in the 10 years since she became homebound, they have faded away. In spite of having lived in her apartment for 19 years, she apparently is not involved with other residents. She says that she feels close to her daughter and four grandchildren 3,000 miles away and they talk by phone every week. But she has not seen them in 7 years. However, a deacon from her church visits weekly; her homemaker has been with her for 4 years; and her doctor, physical therapist, nurse, and now I are also supportive professional resources. She has a cat, acquired as a kitten just before Jack’s death. It is a pleasurable companion. Her daughter-in-law occasionally telephones, but she and her young children have not visited since Jack’s death. Mrs. Ross says she doesn’t understand why, but she has neither asked why nor invited them to visit. So far, she resists my offer to work with her on finding ways to connect with her daughter-in-law and grandchildren. It is hard for her even to discuss or share her feelings about this relationship, beyond insisting that she is rejected rather than rejecting. She is apparently willing to risk estrangement from her grandchildren rather than negotiate a truce with their mother. Opportunities for making new social contacts are severely curtailed, and Mrs. Ross doesn’t “send out invitations.” Thus her isolation is partly of her own making, perhaps because of her emotional vulnerability and her sensitivity concerning her physical disablement. For instance, she describes herself as “ugly” and “crippled.” Physical environment. Mrs. Ross is isolated in her second-floor apartment, which is accessible only by a narrow flight of stairs. The apartment is sparsely furnished but spotlessly clean. Rugs and doors are missing to allow easy access

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for the wheelchair. She is only able to leave her apartment to go to the hospital or the doctor. 5. Level of Fit

The lack of family involvement is a major limitation. The services provided by my agency, other agencies, and the church attempt to meet this void. While these services are essential to her life, they cannot meet the needs for caring provided for by one’s family. Clearly, this needs to be a focus of my helping efforts. 6. Plans 1. More information is needed about Mrs. Ross’s relationship with family members, from their perspective as well as hers. I will need to engage Mrs. Ross more fully in her or my reaching out to her daughter and daughter-in-law. They need to become more involved in her life. 2. Because it takes time to build a trusting relationship, and given Mrs. Ross’s severely stressful situation and my limited time with the agency, I recommend an increase to two home visits a week for the 9 weeks remaining of the 12 agreed on. 3. A carefully planned termination is crucial so that Mrs. Ross has some control over the loss that it will represent. I believe that she is likely to be receptive to transfer to another worker. I am not sure what the agency’s response will be, but I will advocate.

FAMILY ASSESSMENT: MR. AND MRS. CARTER

Background data: Family Services of Hartown is a multiservice mental health setting. In addition to regular business hours, it has early morning, evening, and Saturday appointments in order to accommodate the community. The downtown location on a major bus route makes the agency accessible by both public and private transportation. Intake response is timely and efficient; waiting lists are resolved within a week. A crisis is seen to immediately. Denise Carter, age 35, and Melvin Carter, age 47, are an African American couple living in a suburb with Denise’s two adolescent daughters. They are nonpracticing Protestants. Mr. Carter is a recovering alcoholic, sober six years; Mrs. Carter is a daily beer drinker. The couple married 18 months ago, after living together for two years. Both have been married before. Mr. Carter has three grown children from his first marriage, who all live out of state. After their marriage,

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their arguments about Mrs. Carter and her family members’ drinking turned into screaming matches. Last May, after Mr. Carter lost his job (he charged the employer with racial discrimination), the constant verbal arguments escalated. Mr.  Carter became violent, and Mrs. Carter called the police. In September, Mrs. Carter became violent, and Mr. Carter left home for three weeks. Mrs. Carter initiated counseling two weeks ago, alarmed that the relative calm immediately following Mr. Carter’s return is now replaced by days and nights of constant verbal fighting.

SOCIAL WORK STUDENT’S REPORT 1. Definition of Life Stressors

The couple and I contracted to meet for eight sessions to deal with their maladaptive communication and relationship patterns. At the end of the period, we will consider whether they want to continue to work on their relationship or whether they want help in separating. The focus of our work was clear and mutual. However, I realize that at the outset, I should have also discussed what the work would look like—like that both could not speak at the same time and that I was not a referee. In other words, the content of our work was specified, but the process left undefined. They have trouble listening to each other; their communication styles vacillate between explosions and withdrawal. 2. Family Patterns

Both Mrs. and Mr. Carter come from large families. Mrs. Carter has six siblings, all living in her neighborhood. There is a history of alcoholism in her maternal grandmother’s family, and two of her brothers abuse drugs and alcohol. Mr. Carter’s siblings live out of state. His father, who died 20 years ago, had been a recovering alcoholic for the last 15 years of his life. Mr. Carter and one of his brothers are also recovering alcoholics. Mr. Carter entered a one-month alcohol rehabilitation program 6 years ago; subsequently, he lived for six months in a drug and alcohol rehabilitation halfway house. He has remained sober since then. His determination to stay sober results in a militant antialcohol stance. When Mr. Carter met Mrs. Carter, she was not working and, as both say, was living a partying lifestyle. Both Carters attribute Mrs. Carter’s change in habits—cutting down on beer drinking, maintaining more regular sleep patterns, and finding and holding a clerical job—to Mr. Carter’s encouragement and support.

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Mrs. Carter grew up in a family with fluid boundaries. Today, family members and friends sleep and eat at each other’s apartments with no prior arrangement and, according to Mr. Carter, little respect for individual or marital privacy. Individuals seldom own problems; the group works on them together. This lack of unit boundaries is a crucial issue in the Carters’ marriage. Mr. Carter resents Mrs. Carter’s siblings walking into their bedroom at 11 p.m.; he also resents the time that she spends at her mother’s and sister’s homes. He describes his family of origin as fairly formal. Visitors came to his extended family only by invitation, and friends never blended easily into family situations. He rarely interacts with his own family, and his interactions with Mrs. Carter’s family are mostly limited to breaking up their drinking parties in his apartment and telling them to leave. Communication between Mrs. Carter and Mr. Carter is vituperative, driven at present by Mr. Carter’s increasingly toxic reaction to Mrs. Carter’s drinking. They are so intensely reactive to each other that they have difficulty sustaining any nonvolatile exchange. They alternate between heated fighting and withdrawal—Mr. Carter into silence and television, and Mrs. Carter into her family, friends, and beer. Although both appear to understand the role that environmental factors (unemployment, job, and financial pressures) play in their verbal and physical violence, their animosity is so great that their focus is on blaming each other. The Carters are also currently experiencing the effects of breadwinner role reversal—a reversal that is painful to Mr. Carter and somewhat confusing to Mrs. Carter. Just at the time Mr. Carter was fired, Mrs. Carter received a promotion. Mr. Carter spends his days driving Mrs. Carter to and from her job and looking for work. The isolation of Mr. Carter’s days is not alleviated by contact with peers. Mr. Carter and Mrs. Carter developed friendship patterns as alike as their family relationship patterns are different. They cultivated drinking buddies, people who drifted in and out of their lives, brought together by interest in partying. Mrs. Carter still has these buddies. Mr. Carter, encouraged by his association with Alcoholics Anonymous (AA), avoids his onetime buddies and is now estranged from people that he and Mrs. Carter had in common. Mr. Carter tends to assume the role of “pursuer” and Mrs. Carter the “distancer” in areas of maintaining stable routines, regulating partying, and balancing time spent with each other with time spent with people outside the relationship. Mr. Carter often goes after Mrs. Carter to bring her home from local drinking spots. She pursues him only when she has been drinking. Then she will call him and tells him that she loves him, and also sexually approaches him. He repulses these attempts at intimacy.

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3. Level of Fit

The fit between Mr. and Mrs. Carter is poor, as is the fit between the Carters and their social environment. Mrs. Carter’s drinking and Mr. Carter’s struggle to maintain sobriety lie at the core of their interpersonal and environmental lack of fit. They are simply in different places. The role that alcohol plays in each of their lives dominates their marriage, inhibits normative patterning, and increases the stress to this couple, already faced with the dual life-stage tasks of parenting adolescents and establishing a new family unit. The drinking is the major stressor in the marriage and will require priority in the marital sessions. 4. Plans

The plan is to offer each of the Carters a referral for individual counseling for their alcohol abuse. They have begun to realize that they are in no position to work on improving their communication and relationship patterns while alcohol plays such a significant role in their lives. We will work jointly on this referral so they are able to effectively use this resource. We also will determine how and when they can resume couples counseling to work on their relationship.

GROUP ASSESSMENT: BEREAVEMENT GROUP

Background data. The bereavement support group met from 6–7:30 p.m., once a week for six consecutive weeks at a hospice hospital. All the members had recently suffered the loss of a loved one. The purpose of the group was to provide a safe and supportive environment for members to help each other deal with their loss—with their feelings of loneliness, sadness, isolation, and anger, incorporating the losses in their lives, and reaching out to available support. The group met in a large, well-lit, clean, and attractively decorated room.

SOCIAL WORK STUDENT’S REPORT 1. Temporal Arrangement, Group Size, and Space

The members responded well to the planned short-term nature of the six-session schedule. The time limit kept the work focused, and termination was experienced

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neutrally. The fact that all the members began and ended together fostered a sense of group identity. The fact that many members made connections outside the group facilitated the mutual aid processes. The one-and-a-half-hour period seemed also to work well. Members had energy for the work. The 6 p.m. start time worked well for all but three members, who had very long commutes. They were consistently 5 to 10 minutes late due to heavy traffic. Because the group could not begin earlier and did not want to begin later, these three members’ geographic distances were discussed in the first session and their lateness was accepted by other members. Interestingly, the group saved the “tougher” discussions for after the arrival of the three members. The bereavement group began with 16 members, but 2 members withdrew after the second session. Initially, the group felt quite large, and the members seemed intimidated by it. However, by the second session, group members participated regularly and freely. Only 2 members seemed to hold back. While they attended every session and were involved, a smaller group might have made it easer for them to participate. However, the intensity of the common bond seemed to overcome the potential constraints of the large number of members. Only 2 members did not participate regularly, but they did attend all the sessions. Whether their lack of verbal participation was a result of the large group size, their level of grief, their younger age, or the fact that they were both present with a parent is unclear. The 2 members who left the group after the second session had recently lost their husbands. For both, talking about their losses seemed too difficult. They needed more time to process the loss. They did participate in our next six-session group. For the first two meetings, the group set at a long, rectangular table, with the two of us coleaders sitting at the head of the table. At the end of the second meeting, I shared with the group that the long table seemed to create a barrier to interaction and that the positioning of the coleaders ascribed too much authority to us—making us like teachers rather than cofacilitators. The members agreed, and in the third meeting, the table was removed and chairs were set up in a circle. The members were pleased with the new arrangement, as they could see and hear each other much better. 2. Compositional Balance

The 14 final members of the group were: Diane—An African American in her early fifties, whose husband died last month of lung cancer. She had a difficult time accepting his death in light of the fact that

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he never smoked. In the first three meetings, she expressed a wish to join her husband; however, by the end of the group, she talked about moving on with her life. Betty—A Jewish woman in her mid-fifties, whose husband died eight months ago of metastasized lung cancer. She was a very talkative and supportive member. Rebecca—A Jewish woman in her late fifties. Her husband died five months ago of liver cancer. She was supportive of other members but had difficulty sharing her own pain. Mary—A white, Catholic woman in her early twenties. Her father died of bone cancer two months ago. She hardly spoke in the group, fighting back tears and staying in the shadow of her sister, Stacy, and mother, Barbara. Stacy—A white Catholic in her early thirties. While she actively participated, it was rarely about her grief. She focused on her anger at the medical system and recruited other members to write letters of complaint to hospital administrators. Barbara—Mary and Stacy’s mother, in her early sixties, rarely spoke in the group. When she did speak, her voice was very quiet and difficult to hear. Margaret—An African American woman of Baptist faith, in her early forties, whose husband died two months ago of pancreatic cancer. She actively and supportively participated, easily sharing her feelings. Jennifer—An African American woman of Baptist faith, in her early fifties, whose mother died of stomach cancer a month before the group began. In the first two meetings, she cried and could not talk. By the third meeting, though, she began to participate actively. Jackie—An African American woman of Baptist faith, in her early fifties, whose mother died five months ago of lung cancer. Since her mother’s death, Jackie has retreated from her friends and church. Previously, religion had played a significant role in her life. She could not face her friends asking her how she was doing since her mother’s death. While not active in discussions, her nonverbal communication (i.e., eye contact and body language) were accepting, empathic, and warm. Ted—An African American man in his early fifties. He is Jackie’s husband and came to the group to help his wife grieve. Allen—A Jewish man in his early seventies, whose wife died six months ago of breast cancer, having lived with the disease for 20 years. He was having trouble functioning without his wife. He tended to monopolize discussions. Louise—A Jewish woman in her late fifties, whose husband died a few months ago of bone cancer after a long and painful battle with the disease. She had a very supportive and soothing style. Sheila—Louise’s daughter, in her mid-twenties. She did not speak much and seemed shaken and sad most of the time about the loss of her father.

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Gladys—A white, Catholic woman in her mid-fifties. Her husband died three months ago of bone cancer that had metastasized to the brain. While she was an active and supportive group participant, she tended to minimize her emotions.

This group is obviously quite heterogeneous in terms of race, religion, gender, and age. Also, some have experienced the death of a spouse, while others that of a parent. In contrast, the group is highly homogeneous, in that everyone has experienced the death of a loved one to cancer. The common bond of suffering that a profound loss makes the background differences among members relatively inconsequential. In fact, these differences deepened the quality of exchanges and problem-solving. 3. Mutual Agreement

The purpose of the bereavement group was bringing together people who were struggling and feeling alone with their grief and helping them to help each other deal with their losses together. As cofacilitators, we defined our roles as to aid them in communicating and listening to one another, as well as helping them to heal one another. We reached for their feedback to make sure that the purpose met their expectations. The members were clear about the group’s purpose. The level of mutuality about focus and role expectations was very good, as evidenced by the members’ immediate focus on their grief. While one member had wanted more of a social action group focus, we were able to accommodate to her concerns and effectively integrate her with other group members. 4. Interaction, Friendship, and Role Patterns

Louise appeared to be the internal leader of the group. This came as a surprise to me because, initially, she seemed reserved and unassuming. However, her relaxed manner had a calming effect on the group. She often set the tone for the group sessions. She would often be the first to speak when we opened the group and talked about how the week preceding the group meeting had gone. After a couple of weeks, it became the norm that Louise would speak first, and then the others would follow her lead. Her initiation was welcome and broke the ice. She also set the tone for being honest in her expression of emotions—not glossing over her and other members’ feelings. For example, in one group meeting, Allen expressed a painful emotion, and Rebecca’s response was “You should not feel that way.” Louise responded, “But he does, and I do too sometimes.” This comment refocused the group on the difficult emotions that Allen was experiencing

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and made it possible to continue the work. Interestingly enough, after the first two meetings, other members, following Louise’s lead, ceased cutting off other members’ feelings. For another example, the coleader and I developed problems between us. When our behavior, either verbal or nonverbal, cut off the work, Louise was able to move in and transition the focus off the leaders and back onto the work. In many ways, she was the third coleader—her role was pivotal in moving the work forward. Betty, Rebecca, Margaret, and Sheila assumed the role of supporter. They were naturally empathic, and group members began to look forward to their supportive statements and expressions. Stacy gave voice to anger at the hospital and its medical representatives. Interestingly, while members gave her support in the expression of her complaints, they also made sure that it did not replace the focus on their grief. An implicit agreement developed that allotted Stacy approximately 10 minutes at each meeting to give voice to her anger, as well as the group’s; however, the primary focus remained on their dealing with the loss of a loved one. Allen was the group’s monopolist. However, since his rambling was related to the group’s focus rather than tangential, he was fully accepted. Members would build on his ideas or gently took the floor from him. His despair and loneliness generated much sympathy and acceptance from the other members. 5. Normative and Sanctioning Patterns

As previously discussed, two related group norms evolved: Louise would break the ice and initiate the work; expression of painful emotions was accepted and preferred. Group members also began to have contact before and after the meetings. For example, Louise would have dinner with her daughter in the hospital cafeteria. The first two weeks, they ate alone. However, in the third week, Diane and Margaret joined them, and by the last session, so had Rebecca, Betty, and Allen. Other members who were unable to arrive early enough to have dinner would arrive 10–15 minutes early to the group to have cookies and coffee with the “dinner crowd.” Similarly, some members lingered together after the meeting, exchanged phone numbers, and gave each other support between group sessions. These rituals were established early in the group and were adhered to by members throughout the group’s life. Another group norm that evolved (and was not known until it was broken) was a prohibition against interjecting humor into group discussions to deflect from pain. For example, when Stacy made a joke about her feelings, I normalized her feelings, but Louise and other members were not responsive to the

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joking nature of the comment and moved the work back to where it had begun. The members placed a high value on working on grief and bereavement and the healing process. Louise embodied this group norm—hence she was the group’s indigenous leader. 6. Phases of Group Development

The group did not struggle long, if at all, with the first phase of authority, or the power and control phase. Perhaps dealing with such powerful and connecting issues of grief and bereavement immediately propelled the group toward the intimacy phase. Perhaps the fact that the group members was primarily female accounted for their preoccupation with intimacy rather than testing the leaders’ authority. 7. Transactions with Its Environment

The group was supportive of Stacy’s petition focusing on improving hospital services. Group members also helped each other with dealing with unresponsive family members. However, in the foreground was always the life transition of dealing with loss and expressing pain. The group became a support system wherein they could express their sadness and not be told to “move on” with their lives. 8. Next Helping Steps

The life stressor of the group members’ grief and bereavement was not solved during the six weeks. This would have been an impossible expectation because grief and bereavement require a lengthy process. There was a noticeable difference between the first group meeting, when the focus was on the pain of the loss and the strong need to repeatedly tell the story of the illness and death, to the last couple of meetings, where the focus was on the need to go on with life and establish new identities without the deceased, while remaining connected to the person. If the group had not ended, I would have helped members transition to the emerging themes of rediscovering the self and going on with a new life while holding on to the memories of the deceased. Since it wasn’t possible to continue the group, I spent some time in our last session helping members decide upon their next steps.

Practice Monitoring—Records

Appendix B

of Service

SAMPLE RECORD OF SERVICE (SUMMARIZED): MS. H. Student/Worker Name: Agency: Time Period:

Joe Jackson Bridgetown Hospital October—4 sessions

Check Modality: Individual: __X__ Family:___ Group:____ Community:_____ Professional Helping Area (Indicate Focus): Initial Phase___ Life-Transitional Stressor___ Environmental Stressor _ X__ Interpersonal Stressor Family___ Group___ or Client: Worker___ Ending Phase___.

1. Brief introduction

Ms. H. is a 50-year-old black woman. She was admitted to the rehabilitation center seven months ago, inebriated, after being hit by a car while crossing the street. The accident broke her legs and left them permanently weakened.

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2. Level of mutuality about focus and role expectations

Ms. H and I agreed to work on the difficulties she experienced within the rehabilitation center, and ultimately on needs at discharge, including appropriate housing. 3. Identify the life stressor

The particular life stressor I am examining is an environmental one. The orthopedic medical staff neglects to remove Ms. H’s casts, and she is reluctant to discuss her concerns with them. The environmental life stressor first came to my attention in the second interview. Ms. H. told me that the orthopedist had seen her a couple of days ago but hadn’t removed her casts. She felt she couldn’t ask him why he had not done so. 4. Personal (or collective) and environmental strengths and limitations

Various personality, situational, and organizational factors produce and sustain the environmental life stressor. Ms. H. copes with stress through withdrawal and avoidance. By neglecting Ms. H., the orthopedist gains time for treating the more disabled patients. 5. Present and analyze selected consecutive transactions illustrating your practice over the specified time

For each transaction: (a) Conceptualize your intervention. (b) Provide the actual transaction—the client’s statement and your response. The client’s statement always comes first. (c) Place yourself in the client’s shoes, and in the first person, describe what he, she, or they are thinking, feeling, and trying to communicate to you. (d) Place yourself in the client’s shoes, and in the first person, describe the extent to which your (the worker’s) intervention did or did not connect to what the client was trying to communicate. (e) In the first person, describe what you were thinking and feeling at the moment and how your thoughts and feelings affected your interventions. (f) Another try—based on the client’s message and using what you were thinking and feeling at the moment, how would you now intervene differently? (g) Name your new skill and share your rationale for this new choice.

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Interview #2: Ms. H. told me that the orthopedist came to see her and said that the casts should come off. Several days passed, and he had not removed them. (Casts were periodically removed to check the progress of healing.) First cluster: ms. h: Dr. James [the orthopedist] came to see me and said that the casts should come off. (looking down at her cast) This was two days ago. worker: Ms. H., have you thought of asking the doctor about this?” (1). ms. h: (shrugging her shoulders in a childish manner) I didn’t think I could do that. I don’t think I could understand what he says. Would you do it for me? worker: Yes, I will. (2). (a) Conceptualize intervention: I reached for information. (b) Provide actual transaction: ms. h: Dr. James [the orthopedist] came to see me and said that the casts should come off. (looking down at her cast) This was two days ago worker: Ms. H., have you thought of asking the doctor about this? (1). (c) Place self in client’s shoes: “I want to talk about my anger at the doctor and my concern that there might be something wrong with my legs.” (d) Evaluate from client’s shoes: “You don’t hear my concerns and make me even more anxious by suggesting that I speak to the doctor.” (e) What I am thinking and feeling: “I feel pressure to solve the problem—I feel out of control in the face of ambiguity and begin to rush. What do I do if he forgot about her?” (f) Another try: “Are you worried that he forgot about you?” (g) New skill: Reaching for her underlying concern. ——————————————————————————— (a) Label intervention: I assumed responsibility for the task. (b) Provide actual transaction: Ms. (shrugging her shoulders in a childish manner) I didn’t think I could do that. I don’t think I could understand what he says. Would you do it for me?” Worker: Yes, I will. (2). (c) Place self in client’s shoes: “I can’t talk to the doctor—he hardly speaks English, he rushes in and out of the room, he makes me feel helpless. Please help me.” (d) Evaluate from client’s shoes: “I appreciate your willingness to do it for me, but wish you would ask me more questions—to find out what I am concerned about.” (e) What I am thinking and feeling: “Doing for is comfortable for me—I have always been the one that takes care of things. I feel more in control, more competent. However, I realize that I am making her more dependent. I don’t even ask her what exactly the

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doctor said, if she had tried to speak to him. I must have communicated a lack of faith in her ability to follow through. I am feeling out of control and I can’t stand it.” (f) Another try: “Can you tell me what the doctor said about returning?” If the doctor was ambiguous, I could have followed with “Did you get a chance to ask him when he would remove your cast?” And if my follow-up was required, I should have invited her to plan with me, discussing the comparative advantages and disadvantages of her or my talking to the doctor or our talking to him together. (g) New skill: Reaching for facts, and engaging client in problem-solving.

Interview #3 I arranged a meeting with Dr. James. Second cluster: dr. james: “Please, come into the office.” worker: “Dr. B., is there some reason that Ms. H.’s casts are still on and have not been checked by you?”(3). dr. james: He seemed taken aback, and then said, “I have been very busy, but will take care of it right away.” worker: I thanked him and left (4). (a) Label intervention: I advocated the client’s position directly with the doctor. (b) Provide actual transaction: dr. james: “Please, come into the office.” worker: “Dr. B., is there some reason that Ms. H.’s casts are still on and have not been checked by you?”(3). (c) Place self in doctor’s shoes: “I wonder what she has on her mind.” (d) Evaluate from doctor’s shoes: “What a self-righteous jerk—who does she think she is! I have been negligent, so I better not retaliate.” (e) What I am thinking and feeling: “I am furious at this doctor—he doesn’t care about Ms. H. I want to deliver for her. I know you will want to know how come I am so angry, what is being triggered. Well, a similar thing happened to me when I was a patient—I can’t believe how passive I was. I became overidentified with the “helpless” client and marched into battle. My advocacy did not represent an assessment-based intervention, but rather an expression of my own experiences and feelings. In retrospect, my initial intervention should not have been adversarial since I had never met the doctor and had no evidence that he would be antagonistic. (f) Another try: “Ms. H. is concerned about the delay in the removal of her casts. She had wanted to ask you about the delay, but I remember when I had surgery it is very difficult to ask a question—everything happens so fast.” (g) New skill: I clarified the situation. ———————————————————————————

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(a) Label intervention: I shared my appreciation. (b) Provide actual transaction: dr. james: He seemed taken aback, and then said, “I have been very busy, but will take care of it right away.” worker: I thanked him and left (4). (c) Place self in doctor’s shoes: “I resent your tone of voice. I am the doctor and you are the social worker. But I better do it because I have not followed up. I will get even with her at another time.” (d) Evaluate from doctor’s shoes: “That’s better—at least she thanked me, but I still don’t like her tone.” (e) What I am thinking and feeling: “Oh! Oh! I hope he doesn’t report me to my field instructor. My anger threw him, but it also scared me. I realize that I have a ‘slush fund’ of anger at men with power. They have a way of making me feel small and incompetent.” (g) Another try: “Dr. James, I want to apologize for my tone. Ms. H.’s situation reminded me when I was in the hospital and felt too intimidated to ask questions. I realize we have never even met—could we start over?” (h) New skill: I demonstrated congruence and humility.

6. Where things stand now

As soon as I gave Ms. H. support and began via role-play to stimulate her latent interest in participating, she made progress in “trying on” a bit of assertiveness with the doctor. She became less depressed  .  .  . (student elaborated upon the current status of the case) 7. Next helping steps (hypothetical if no longer working with client)

I plan to continue involving her in acting on her social environment. She had found role-play helpful in preparing for and dealing with the physician and other staff . . . (student elaborated upon next steps) 8. Apply theory and research findings

A review of relevant literature brought the environmental obstacle into clearer focus. Berman-Rossi, T. (2005). Older persons in need of long-term care. In A. Gitterman (Ed.), Handbook of social work practice with vulnerable and resilient populations, 2nd ed. (pp. 715–768). New York: Columbia University Press . . . (the student elaborated upon the theoretical and empirical literature)

Practice Monitoring—

Appendix C

Critical Incidents

1. SUMMARIZED SAMPLE CRITICAL INCIDENT (ANALYSIS OF INDIVIDUAL TRANSACTIONS) Student/Worker Name: Agency: Time Period:

Angela Sampogna York Mental Health Clinic 12 weeks

Check Modality: Individual_____ Family_____ Group__X__ Community____ Organization____ Professional Helping Area (Indicate Focus): Initial Phase____; Life-Transitional Stressor____; Environmental Stressor____; Interpersonal Stressor (Family___, Group___, or Client: Worker___); Ending Phase_ _X_.

1. Group formation

A total of 20 eighth grade girls were interested. They were divided into two groups, each to meet for 12 weeks. When one group ended, I began the second group.

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Each group had 10 members. All the members had been in the same class for at least two years, and several had been together since kindergarten. They all lived in low-income public housing in a neighborhood where drug trafficking and associated violence were part of everyday life. The homogeneity in background and geography provided a common frame of reference that enhanced cohesion and promoted mutual aid. Half the girls were Puerto Rican and half were black. However, friendships were not based on racial and ethnic backgrounds. These youngsters had known each other for so long that the building they lived in was more defining than race. The girls identified themselves as a single entity in terms of their income level, neighborhood, school, class, and group. We met in a small alcove in the library. Because the library was not open in the morning, the space provided the group with essential privacy. 2. Agency context

Group services were offered to all eighth-grade students in my school. They were divided into two groups. These groups were assigned to two interns from an outside agency. There were some rough spots in the development of the group services, many of which could have been avoided had we taken the initiative to involve the principal in the service creation. We had not realized the importance of developing vertical as well as horizontal organizational sanctions and supports (Gitterman, 2005). We had worked out with the guidance counselor that the groups’ memberships would be voluntary, with a focus on the youngsters helping each other to work on common life issues. It had never occurred to us that the principal had a different perspective. He wanted the focus to be on changing disruptive and undesirable behaviors in students who had been identified as problems, and he wanted the group to be mandated for them. There were four children who had not signed up for the groups that he strongly felt needed to be in them. The compromise that we worked out was that these four children would receive intensive individual help and the groups would continue in the direction charted by the interns and guidance counselor. 3. Level of mutuality in focus and role expectations

When we met individually with each girl and again in the first group meeting, we explained that the group was a place where the girls could help each other with things going on their lives that they would like some help with—things going on at school and at home, with boys, other girls, and their bodies. That is all the

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invitation the girls needed. They had been waiting six months for this group, and they took off. They were on task, knowing that the group would end in 12 weeks. 4. Define life stressors

The focus of this critical incident is my effort to help the girls with termination. In spite of the fact that these girls had been friends and classmates for a long time and would still be together after the group ended, they had developed a newfound intimacy, trust, and mutual aid. When the issue of termination came to the fore in the seventh meeting, I was totally unprepared (my fault, as I was in my own denial) for the intensity of the members’ reactions. The predetermined number of meetings had been discussed in the individual meetings, as well as the first group meeting, and I had naively assumed that they were aware of the number of meetings left as time passed. The ending date also had been mentioned “in passing” during earlier sessions without evoking visible reactions. Yet, in the seventh session, I found myself confronted with much greater anger than I had anticipated. In retrospect, I realize that termination triggered many countertransferrential issues, and I was just in as much avoidance and denial as the youngsters. I have my own issues about abandonment, which makes endings and separation very difficult for me. 5. Social and normative structures, phases of group development, relationship to its social and physical environments, and level of fit

Alice and Inez assumed the roles of the group’s indigenous leaders. Because of her competent, take-charge manner, Inez emerged as the task leader. Alice emerged as the “socioemotional” leader, in that she was most attuned to what other members were feeling and able to help them verbalize it. Nora had the role of work deflector, and Maria fell into the role of scapegoat. Both members, with the group’s assistance, do their jobs real well when group discussions get intense . . . A very strong group norm was that fathers were not to be mentioned. Although I tried to point out the omission on a few occasions, the group members creatively sidestepped the topic or remained silent. Interestingly, during termination, a few members talked about losing their fathers to the competing needs of stepfamilies. The loss of the formal group triggered discussion about other losses in life . . . Developmentally, the group moved very quickly through the first stage, “preaffiliation,” because the members knew each other so well (Garland, Jones,

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& Kolodny, 1965). In the “power and control” stage, the members tested me by having Inez sit in my seat for the first meeting. I passed the test by pulling my chair next to her and leaving her with a more prominent position, while at the same time conveying that I was the adult professional who would make the experience safe and productive. 6. Critical incident

Context for the incident—This was the seventh meeting, and it had been going very well. The discussion had centered on the girls’ frustration and anger with their mothers’ “lack of trust,” as demonstrated by their “unreasonable and overprotective” attitudes about boys, parties, and curfews. The highlight of the discussion came when the members agreed to do a role reversal and become a group of their mothers, who in turn discussed their fears and aspirations for their daughters. We had much fun with the role reversal; the group members were very animated and “hammy,” yet insightful, and at times poignant, as they bounced back and forth between roles. Keika reminded the group that next week was the last time we were going to meet before the holiday and asked if we could have a party during the last half of the meeting. I agreed that it would be fun and pointed out that today marks the halfway mark for the group. (1a) Perhaps they would like to spend some time at the beginning of the next session to take stock and decide the focus for the remaining meetings. (1b) Within a few seconds, the entire ambience completely changed. Although a few registered no visible reactions, most seemed puzzled as they glanced around the room. Alice, Helen, and Maria, who were seldom at a loss for words, looked absolutely thunderstruck. All were quiet. I waited several minutes, (2a) and then observed that they were awfully quiet all of a sudden, and I was wondering if my comment about having only five more sessions had caught them off guard. (2b) The silence just got louder. For a few minutes, I had the sinking feeling that the session might end in silence. Finally, Ivory found her voice and demanded to know why I was cutting the group short when they hadn’t done anything “nasty.” Then she looked more closely at me and reminded me that I had said I was going to be here until May, so what was the problem? Matilda chirped in a “told you so” tone of voice that I just did not like them—that was the problem. I became flustered and defensive. I mentioned that in individual interviews and at the first meeting I had emphasized the group would meet for 12 weeks. (3) Ivory retorted that when I had first talked to their class, I had said the group would meet for the entire school year, just like last year’s group.

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Inez shook her head and corrected her by pointing out that it had been changed to 12 weeks because too many people signed up. Ivory indignantly declared this was the first she had heard of it. But even if that was the case, why couldn’t I just have a second group for the other class? I explained that if they remembered, I had informed them right away that my schedule did not allow me to have two groups, and the agency could not assign another worker. (4) Dramatically, Ivory looked around the group and said in exaggerated disbelief that “I just want to get this straight . . . you are going to give our group to those bimbos?” I responded this was very hard for all of us. (5) There was a tense lull, and finally Maria said quietly that it seemed like we had just started, and now we only had a short time left. I agreed, saying that we had come such a long way in such a short time, and it’s hard to make peace with only five more meetings. Keika responded that she was upset, but if I had taken the other group first, she would expect them to finish on time so her group would have a turn. Alice was animated again and informed me I was going to need a bigger room to have a group with “those ho’s” because the only way they know how to talk is when they are lying down. 7. Practice Analysis (individual transactions):

1. Keika reminded the group that next week was the last time we were going to meet before the holiday and asked if we could have a party during the last half of the meeting. I agreed that it would be fun and pointed out that today marks the halfway mark for the group. (1a) Perhaps they would like to spend some time at the beginning of the next session to take stock and decide the focus for the remaining meetings. (1b) A) What is your present understanding of what the group members are trying to communicate to you (in the members’ voices)? Keika’s voice: “I want to communicate the good feelings and sense of closeness that is evolving in the group. I am invested in what we talk about—that is why I am suggesting only a half hour be devoted to the party.” Group’s voice: “We love the idea of celebrating our closeness.” B) What was the purpose or intention behind your response (or silence)? My response began as reinforcement of those good feelings and to support the notion of the importance having fun as well as our work. I was especially pleased at the moment that this session had been a landmark point where a deeper level of intimacy and mutual aid had been achieved. I found myself thinking that it was such a shame to have to terminate at this point in the group’s life. My thinking found its way into my tongue. I cannot say that it was a deliberate intervention.

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C) How did the group members experience and evaluate your intervention(s) (in the members’ voices)? Group: “What is she talking about—this group is not ending in a few weeks. Something must be wrong. Her timing sucks—we are planning a party and she drops a bomb.” D) If your interventions were inconsistent with the members’ messages and/or your intentions, examine what interfered with your ability to respond to the members’ messages (in your voice)? Although the halfway point is theoretically an optimal time to take stock and to remind members that our time together is precious, my abrupt “doorknob” comment was a reflection of my own separation anxiety. I had a sinking feeling—it suddenly hit me how much I was going to miss these kids, and that this wonderful group was going to have to end. E) Based on what you know, how would you respond differently? (Be specific.) If I could do this intervention over, I would raise termination at the beginning of the meeting rather than at the end. “I know this going to be hard to talk about, and part of me would prefer not to have to think about it, but we do need to talk about that after today’s meeting we only have five meetings left.” This puts it out in a real way and invites work. 2. Within a few seconds, the entire ambience completely changed. Although a few registered no visible reactions, most seemed puzzled as they glanced around the room. Alice, Helen, and Maria, who were seldom at a loss for words, looked absolutely thunderstruck. All were quiet. I waited several minutes, (2a) and then observed that they were awfully quiet all of a sudden, and I was wondering if my comment about having only five more sessions had taken them off guard. (2b) A) What is your present understanding of what the group members are trying to communicate to you (in the members’ voices)? Group: “What is she talking about? The group has a long time to go. We can’t be half over. She must be leaving us—another adult abandoning us.” B) What was the purpose or intention behind your response (or silence)? I let the silence linger for a while because I sensed that they were experiencing the same anxiety that I had felt a few seconds earlier. However, they were stunned. I wanted to verbalize that my observation caught them off guard. I wanted to reach inside the silence and check out my perceptions. C) How did the group members experience and evaluate your intervention(s) (in the members’ voices)? “I am having trouble breathing. She just took my breath away. Why is she being so quiet, and what is she talking about?”

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D) If your interventions were inconsistent with the members’ messages and/or your intentions, examine what interfered with your ability to respond to the members’ messages (in your voice)? Same as previous one— E) Based on what you know, how would you respond differently? (Be specific.) I would skip the silence—it only made them more anxious. 3. The silence just got louder. For a few minutes I had the sinking feeling that the session might end in silence. Finally, Ivory found her voice and demanded to know why I was cutting the group short when they hadn’t done anything “nasty.” Then she looked more closely at me and reminded me that I had said I was going to be here until May, so what was the problem? Matilda chirped in a “told you so” tone of voice that I just did not like them—that was the problem. I became flustered and defensive. I mentioned that in individual interviews and at the first meeting I had emphasized the group would meet for 12 weeks. (3) A) What is your present understanding of what the group members are trying to communicate to you (in the members’ voices)? Inez: “I am shocked and furious. I love Angela. There must be some explanation.” Group: “Did we do something wrong? Does she not care about us? Is it beyond her control?” B) What was the purpose or intention behind your response (or silence)? I wanted to provide important information. C) How did the group members experience and evaluate your intervention(s) (in the members’ voices)? “What is it—why are you leaving us—we have to find out! You’re withholding from us.” D) If your interventions were inconsistent with the members’ messages and/or your intentions, examine what interfered with your ability to respond to the members’ messages (in your voice)? I became defensive—the information was to defend myself, not to help them. E) Based on what you know, how would you respond differently? (Be specific.) I would remind them, but in a much softer and less defensive manner. 4. Inez shook her head and corrected her by pointing out that it had been changed to 12 weeks because too many people signed up. Ivory indignantly declared this was the first she had heard of it. But even if that was the case, why couldn’t I just have a second group for the other class? I explained that if they remembered, I had informed them right away that my schedule did not allow me to have two groups, and the agency could not assign another worker. (4) A) What is your present understanding of what the group members are trying to communicate to you (in the members’ voices)?

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Inez: “I got to take some heat off Angela. I hope they don’t get mad at me. But I do remember our conversations.” Ivory: “I have no recollection of what she says—we are supposed to be meeting the entire school year.” Group: “We are very upset—yeah, we remember the conversations—so what—we love this group.” B) What was the purpose or intention behind your response (or silence)? Just feeling defensive and defending myself. C) How did the group members experience and evaluate your intervention(s) (in the members’ voices)? “Uh-oh—she is getting mad. She sounds like a lawyer. What happened to Angela? She is not connected to us.” D) If your interventions were inconsistent with the members’ messages and/or your intentions, examine what interfered with your ability to respond to the members’ messages (in your voice)? Help! I am drowning in guilt. I feel like a child again having to defend myself. I didn’t lie—please love me. A flash of anger for being wronged too often follows the guilt. It is happening at the moment. I am missing the point. It is irrelevant who said what to whom in what time frame. We are all very upset that the group will be ending in five weeks and we need to take that reality in. I need to be seen as “a good guy.” I hurt to the core when I feel falsely accused— again, like a little child being scolded by my parents. I really love these kids, and to be perceived as insensitive, uncaring, hard-nosed—it hurts—I feel raw. E) Based on what you know, how would you respond differently? (Be specific.) “I know you feel that I am backing out, and I feel terrible about this.” 5. Dramatically, Ivory looked around the group and said in exaggerated disbelief that “I just want to get this straight . . . you are going to give our group to those bimbos?” I responded this was very hard for all of us. (5) A) What is your present understanding of what the group members are trying to communicate to you (in the members’ voices)? Ivory: “You are picking those other kids over us—you gotta be kidding. Group: “It is not fair!” B) What was the purpose or intention behind your response (or silence)? To verbalize the common feelings! C) How did the group members experience and evaluate your intervention(s) (in the members’ voices)? Group: “She finally seems interested in what we are feeling.” Ivory: That’s exactly what I am feeling—just don’t give me any bullshit excuses.”

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D) If your interventions were inconsistent with the members’ messages and/or your intentions, examine what interfered with your ability to respond to the members’ messages (in your voice)? I feel I am getting closer and beginning to reverse my self-defensiveness. I am beginning to relax. E) Based on what you know, how would you respond differently? (Be specific.) “We all are upset that the group will be ending in five weeks—what are the other members’ reactions?”

8. Present the status of life stressors

In the analyzed incident, the group and I experienced all the phases of termination. We avoided and denied the ending, expressed anger and sadness, and the group began trying it out for size by envisioning themselves being back in class. In the next meeting, about half the girls were absent from school. The group decided just to eat their refreshments and have no discussions because of the absent members. In the first meeting after the Christmas holidays, all the members were present and got into a discussion of family members who had left them in their lives. The discussion was poignant in itself, and even more so given the group’s impending termination. A few members insightfully shared how they learned to leave people first before they left them, so that they would not be hurt. I connected this insight to the poor attendance at the prior meeting. While they were not ready for that connection, they began to reminisce about the group and recount their favorite expressions and uses of speech coming from me (e.g., “I am going to bite your nose”). They were giving me a beautiful gift, and I appreciatively accepted it. When they finished, I offered my list of favorite expressions of theirs. We roared with laughter and tears in our eyes. 9. Next helping steps

I would like to prepare members for life after the group. I plan to use the thirdto-last meeting to help them to meet together without me. These kids can really help each other. In the next-to-last meeting, I would like, for at least part of the meeting, for them to meet as if I were not there, and then for us to evaluate what was done well, could be done better, etc. I am unsure about the last meeting—will involve the group in deciding.

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10. Theoretical concepts and research findings that support and/or challenge practice analyses, and next helping steps

The conceptual and empirical readings related to termination … (student elaborated upon relevant theoretical and empirical literature)

2. SUMMARIZED SAMPLE CRITICAL INCIDENT (ANALYSIS OF TOTAL INCIDENT) Student/Worker Name: Agency: Time Period:

Alicia Parker Metropolitan Emergency Psychiatric Services 12 weeks

Check Modality: Individual__X___ Family_____ Group____ Community____ Organization____ Professional Helping Area (Indicate Focus): Initial Phase____; Life Transitional Stressor_X_; Environmental Stressor____; Interpersonal Stressor (Family___, Group___, or Client: Worker___); Ending Phase____.

1. Case summary

Maria, a 9-year-old Latina, temporarily lives with her great-aunt, great-uncle, and 18- and 5-year-old third cousins in an urban area. She is learning disabled and has repeated the second grade twice. Maria moved from Mississippi about four months ago, where she lived with her biological mother and a younger brother and sister. Her father was in jail for grand larceny. Maria and her great-aunt reported that she was moved because her mother could not care of her anymore. The great-aunt received temporary custody. 2. Agency context

The agency is Metropolitan Emergency Psychiatric Services (EMPS). The agency serves children 4–18 years of age. EMPS responds to calls for children and adolescents who have suicidal or homicidal ideation or other crises. Once an assessment has been completed, the agency provides the youngster and her/his family with in-home counseling. The agency was contacted by Maria’s school due to her repeated outbursts and

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suspensions. She frequently initiated verbal and physical fights with peers and teachers. Maria also disclosed to the school social worker that she wished she were dead. 3. Level of mutuality in focus and role expectations

I met with Maria and her great-aunt at the school. I explained that I was a social work intern with an agency that worked with children and adolescents who were not feeling good about themselves, overwhelmed with tough life experiences and their current situations. As a way of expressing that hurt, these kids wound up hurting themselves and others. I further explained that the school contacted me because Maria has had many verbal and physical fights with other kids and teachers and let it be known that she wished that she were dead. I explained to both that I did not work for the school and that I would not be informing them about what we had talked about. I was here to help Maria and her great-aunt with their pain, not to represent the school. I wanted them to know that they could refuse my offer of service—that it was not required—that it was their choice. If they were interested, we could meet for 6 to 12 weeks, whether at the school or at their home. I commented on how sad Maria looked and asked for her reactions to what I stated. Maria agreed that she was sad, angry, and alone—that no one listened to her and that she needed someone to talk with. I said that we could work together to understand how she felt and how it was connected to her life circumstances, like living away from her mother and brother and sister. She agreed to meet with me. I also offered to meet with her great-aunt about her concerns, and she also accepted. 4. Define life stressors

Maria is dealing with simultaneous and cumulative life transitions. First, she recently moved from Mississippi. During this move, she was separated from her mother, siblings, friends, and familiar physical environments (home, neighborhoods, school). At the same time, she moved into a new neighborhood, school, and house, living with various family members whom she had not even met in the past. She lives in a high-crime neighborhood that is full of violence. This prevents her from being allowed to go outside to play (she played outside every day in Mississippi). 5. Level of fit between personal strengths and limitations and environmental resources and gaps

Maria and her great-aunt accepted services offered by EMPS and have continued to be highly motivated and involved in the services. This is a major

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strength. For example, Maria consistently implements tasks agreed on (talking to a teacher about a concern, reaching out to a peer). The great-aunt is open to my suggestions and actively involved in family counseling. Maria has made friends, and they have become part of a new support system. In reaching out to her father’s family, they also have been responsive and have expressed their love. Maria has found great comfort in her extended family and new friends. I am very pleased with this highly improved level of fit. What strains the fit is that Maria had pronounced learning difficulties, and it will be difficult to sustain her learning motivation, as well as the school’s commitment to her. Her mother remains verbally abusive and is a negative force in Maria’s life. Maria’s father, being in jail, also represents a significant gap in her life. There are frequent battles between the two families, and Maria feels the pressure to choose which family she loves more. Maria’s neighborhood is also an important constraint. These limitations and resource gaps strain the current level of fit that has been achieved. It clearly indicates that without an outside agency, Maria is at serious risk. I am currently working on a referral to a community agency. 6. Critical incident

Context for incident—Over a period of five weeks and biweekly meetings leading to this critical incident, Maria and I have been discussing all the changes that have occurred in her life. We traced the progression and course of her sadness and feelings that her mother did not love her anymore, culminating in her being sent away to be “someone else’s problem.” She pieced together all the people in her life and how they all saw her as a problem. She felt “ugly and stupid.” Her mother repeatedly told her that she was not as cute as her younger sister. I am presenting an incident from our sixth meeting. She had been suspended that day from school for swearing at the teacher. As punishment, her great aunt stated that she could not go to her parental grandparents’ house for the weekend, as had been planned. Maria is extremely angry and crying: maria: I hate her [great-aunt]. She never let’s me do anything (angry and crying). worker: (holding her hands). I feel real badly for you (1a)—you feel like you have no control over your own life. (1b) maria: Yeah . . . how can she keep me from my dad’s family? It’s like she wants to find every reason to keep me away. worker: You must feel like you are stuck in the middle sometimes. (2a) Your dad’s family is important to you. (2b)

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maria: (sobbing) I am going to have to explain why I can’t see them and they’ll get mad and I can’t even explain because SHE WON’T LET ME TALK TO THEM ON THE PHONE!!! (screaming). worker: I understand how upset and angry you are. (3a) They mean a lot to you and you feel their support and you don’t want to lose them. (3b) maria: (crying) Well . . . yes! What difference does it make what I do? I get in trouble for everything. She is trying to have my dad’s family push me away too. worker: I understand your worrying about losing them. You have experienced many losses—much too much for someone your age. (4) maria: (crying) I’m not perfect. worker: Are you afraid that if people do not feel you are perfect, they will not care about you? (5) maria: (crying) Yes. They want me to be perfect, or else. worker: You don’t have to be perfect for me. (6a) I care about you and understand that you are living in a lot of pain right now. (6b) maria: It’s a mess. I have no one. Mom didn’t want me (starts crying again). worker: I can see that you feel no one cares about you. You feel that there are many people swirling around you, yet no one is paying attention to you. (7) maria: (crying) THAT’S BECAUSE THEY DON’T CARE (yelling)!!! Look at your face—I can tell you feel sorry for me, like I’m broken. worker: I am concerned about you, but I do know that you are strong and a survivor and that you can get through this. (8) maria: I can’t even go outside. I can’t go anywhere. I can’t do anything, like I’m in prison. worker: Do you think if your Dad were around, things would be different? (9) maria: Yeah . . . then I could stay with him and my grandparents. It would be better. Now I have to sit here all weekend. I can’t even call my mother until I’m off punishment. worker: How would your dad make things different? (10) maria: He never would be so mad at me all the time. He wouldn’t expect me to be perfect ’cause he isn’t, ’cause he is in jail. worker: You want to live in a place where you felt loved and people paid attention to the good parts of you too. (11) maria: Yeah, I can be good sometimes. worker: I know you can—that is the part I mostly see. (12)

7. Practice Analysis (total incident): A) What is your present understanding of what the client is trying to communicate to you (in the client’s voice)?

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Maria is saying to me: “No one cares about me. Even my own mother doesn’t care about me. Why should anyone else care about me, including you? Why should I care about myself? My great aunt wants to control me—not love me. I am trapped and I HAVE NO CONTROL OVER MY LIFE.” B) What was the purpose or intention behind your response (or silences)? I wanted to help Maria to verbalize her underlying feelings and to legitimize her pain. I also wanted her to reflect on the meaning of her experiences. C) How did the client experience and evaluates your interventions (in the client’s voice)? “The worker is mostly connected with my feelings of anger, loss of control, and hopelessness. She gets how I am feeling, but she doesn’t understand the depth of my pain. She could have conveyed a greater empathy for my despair. She gives me some glib reassurance rather than deal with the part of me that feels like a broken doll, hopeless, helpless, and trapped. Why is she talking so much about my dad?” D) If your interventions were inconsistent with the client’s messages and/or your intentions, examine what interfered with your ability to respond to the client’s message (in your voice)? Although many of my interventions were connected to the client, when I place myself back into the moment, I remember feeling some disappointment with Maria for getting suspended. We had worked very hard and she had been showing marked improvement in school. I am struggling not to have my disappointment affect my interventions. On the one hand, I realize that I should not feel that Maria let me down; yet on the other hand, there is a part of me that feels let down. I am struggling with my narcissism—that the school staff will see the suspension as a reflection of my practice. I am also struggling with much anger at Maria’s great-aunt. Denying her contact with her dad’s family seems overly punitive. Maria’s anger and resentment became my anger and resentment. I am overwhelmed by the chaos in Maria’s life. I totally miss her feelings of being broken in transaction #8. I know the feeling of feeling unloved, the despair of feeling that there must be something wrong with me—I know that feeling much too well. E) Based on what you know, how would you respond differently? (Be specific.) Based on getting closer to my experiences at the moment, I would have shared as a child that I too felt a similar despair. She read my face as one of pity for her—it was pity for myself. I needed to be much more real with Maria. I am fighting against myself—so worried about my own feelings spilling into the work that I remove them all and keep a distance from Maria. In transaction #8, I could have said, “I too had trouble with my mom when I was your age—I know how hopeless life can feel without a mother’s love and support. But I made it, and I want to help you make it.” That is much closer than telling her that she is strong and a survivor when she feels so week and victimized.

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8. Present status of life stressors

In relation to the life-transitional stressors, I have helped Maria to mourn, to mourn some more, and even some more. Over time, the festering wound began to be less raw and heal a little. While working on her losses, we also worked hard on improving Maria’s relationship with her great-aunt. Maria and I worked on it; the great-aunt and I worked on it, and all three of us worked on it. Slowly, the great-aunt is becoming the stable life force that Maria never had. The great-aunt has learned to provide love and support alongside with the discipline and consequences. When I praised the great-aunt’s efforts, she responded, “It’s a Latin thing—love, support, and lots of family.” And Maria has responded extremely well to the great-aunt’s support and involvement of other family members. Maria also suffered from being labeled as a “troublemaker” in school. Over the years, she internalized the label. I worked with her teachers and administrators to see her differently: as a child hungry—starved for love, support, and praise. Slowly, the transactions between Maria and school personnel began to change. Currently, she is being tested for a clear picture of her learning disabilities and will obtain additional learning services. Maria and I also worked on getting her connected in the community. She loves to play baseball, and I got her connected to a girls’ Little League team. She turns out to be a very good player, and her coach has been very supportive and attentive. From this experience, she has begun to make new friends. 9. Next helping steps

Termination and referral will be the focus of my future work…(student elaborated upon next steps) 10. Theoretical concepts and research findings that support and/or challenge practice analyses, and next helping steps

The current research on abandonment trauma . . . (student elaborated upon relevant theoretical and empirical literature)

Force Field Analysis

ORGANIZATIONAL ANALYSIS

Appendix D

High High

Threat to staff ’s job security.

Interest and availability of community agencies for collaboration.

High

Formalization: modest number of rules, but not rigidly enforced, often left ambiguous (e.g., job descriptions not defined, leaving opportunity for community work).

High

Low

Intensity

Interpersonal Forces

High

Decentralized: in competition with other branches.

High

Intensity High

Complexity: employs a variety of professionals; historically has been somewhat unorthodox.

Administrator is experiencing environmental pressures, is liberal in views, and active.

Moderate

Low

Low

Organizational Forces

High

Intensity

Environmental Forces

Coordinating agency’s loss.

Supports

Opposition

Administrator sometimes doesn’t follow up.

Decentralization and formalization; staff given wide latitude, with limited accountability.

Current collaborative arrangements.

Undeveloped community relationships.

Coordinating agency’s threat of funding loss of some control over accountability.

• Agency: Branch office, sectarian family agency • Problem: Intake limited to self-referral, excluding many potential clients from service • Desired outcome: To reach more clients • Means for implementation: Community outreach demonstration

Low High

Educational consultant is invested only in school collaboration and will not restrain my efforts.

Total work group: high identification with branch, and perception of themselves as innovative and creative, and committed to serving their population.

Highly motivated and has the time and energy to undertake this influence.

High

Moderate

Recent-graduate status provides legitimacy to experiment.

Low

Low

Intensity High

Supervised by administrator, therefore has easy accessibility to critical participants.

Personal positioning includes excellent informal relationships, and the worker is perceived as highly motivated; on several occasions, worker has demonstrated competence in community contacts.

High

Low

Low

Moderate

Moderate

Worker Influence

Moderate

High

Moderate

Psychiatrist is relatively uninvolved, follows the administrator.

The social workers are quite liberal and client-oriented.

Psychologist is service-minded, concerned about the decline in the number of clients served.

Motivation might be suspect.

New-worker status limits right to undertake a new project.

Total work group: outreach could potentially mean more work, travel, uncertainties, and contact with less-motivated clients.

Educational consultant may be threatened; however, he has the lowest organizational status.

Psychiatrist may be threatened by the outreach administrator.

The social workers have relatively low status and limited influence.

Psychologist is inactive in the decision-making process.

Notes

PREFACE 1. The term life model is used interchangeably with life-modeled practice in order to add still greater emphasis to the fact that the practice is patterned on natural life processes.

1. SOCIAL WORK PRACTICE AND ITS HISTORICAL TRADITIONS 1. At the time of publication of this text, the United States and countries around the world were in midst of the COVID-19 pandemic. It is likely that the health and income disparities the authors present here will significantly increase as a result.

3. THE LIFE MODEL OF SOCIAL WORK PRACTICE: AN OVERVIEW 1.

We acknowledge Professor Lawrence Shulman for this insightful formulation.

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4. CULTURALLY COMPETENT AND DIVERSITY-SENSITIVE PRACTICE AND CULTURAL HUMILITY 1.

Used with permission of the author and publisher.

5. ASSESSMENT, EVIDENCE-GUIDED PRACTICE, AND PRACTICE EVALUATION 1. We wish to acknowledge the contributions of the late Professor William Schwartz for the development of these instruments more than forty years ago.

8. HELPING INDIVIDUALS, FAMILIES, AND GROUPS WITH STRESSFUL LIFE TRANSITIONS AND TRAUMATIC EVENTS 1. We acknowledge Professor Lawrence Shulman for the clarity of this formulation. 2. This practice illustration and discussion are presented in and adapted from Gitterman (2004).

9. HELPING INDIVIDUALS, FAMILIES, AND GROUPS WITH ENVIRONMENTAL STRESSORS 1.

This illustration and discussion draw on Gitterman and Miller (1989).

11. HELPING GROUP MEMBERS WITH MALADAPTIVE COMMUNICATION AND RELATIONSHIP PATTERNS 1. We prefer the concept of phases rather than stages. Stage models assume a linear, fixed, sequential, and predictable group process. In reality, though, each group develops somewhat differently and elaborates unique group processes. A group of sexually abused group members might be initially preoccupied with trust rather than authority issues.

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13. ENDINGS: SETTINGS, MODALITIES, METHODS, AND SKILLS 1.

This illustration first appeared in Irizarry and Appel (2005).

14. INFLUENCING COMMUNITY AND NEIGHBORHOOD LIFE 1. This case example first appeared in Knight, C. & Gitterman, A. (2018). Merging micro and macro intervention: Social work practice with groups in the community. Journal of Social Work Education, 53, 1-15.

16. INFLUENCING LEGISLATION, REGULATIONS, AND ELECTORAL POLITICS 1. Unfortunately, as of this writing, the law remains unfunded and has not been renewed. 2. In this discussion, we focus on the regulations regarding IEP team composition in this one state. The social workers on the student’s IEP team dealt with the practice challenge associated with the father’s prohibition about discussing his child’s transgender status.

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Index

AA. See Alcoholics Anonymous AAGW. See American Association of Group Workers AASGW. See American Association for the Study of Group Work abuse or misuse, of power, 2, 55, 61 accredited program, for social workers, 632 acknowledgment and verbalization, of feelings, 151, 239 actions, 2, 262; of clients, 3; collective, 550–553, 574–575; coordinated public, 572–574; organizational engagement conflict and, 608–609; professional ethical, 101; in stage of change, 156, 158; worldview orientation to, 116. See also social action activity: art group, 425; communities change strategies for social, 568–570; group skills use of, 442; guiding skills

for engagement in, 277; helping process beginning use of, 246–247; methods and skills for legislation, 103; regulatory process prehearing and posthearing, 635–636, 637; sexual, 245, 332 actual level of fit, 58 adaptation, 2, 59, 60; level of fit and, 55 adaptedness, 2, 58, 59, 60; power enhancement by, 62 adaptive communication, family secret example, 379–380 adaptive exchanges, in person:environment, 58, 60 Addams, Jane, 8, 9 Addiction Severity Index, 170 administration: social method of, 27–28; social work curriculum on supervision and, 28 Administration for Children and Families, 49

INDEX

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720

adolescence: autonomy in, 57; bullying of LGBTQ, 123; Ethical Principles Screen on pregnancy of, 92–93; gang violence stages of change example, 220–222; gender and mental health of, 122; group practice illustration on denial and pregnancy in, 451–453; health clinic example, 589; IEP for transgender in, 633–634; informed consent exceptions for, 89; juvenile justice system and, 78–79; LGBTQ homeless example, 186– 187; rap group for residential treatment of, 426; sexual identity example, 435; substance abuse example, 269; teacher mediation example, 350–351; transitions and loss in early, 260–261; truancy anticipatory empathy example, 181–182, 192–193; violence witness group for, 428–429. See also juvenile delinquency; youth diversion program adoption, life book example for, 477–478, 505–508 adult, substance abuse example, 269–271 adult survivors, of sexual abuse: depression of, 78; diversity sensitivity example, 141–142; eating disorder example, 153–154; life transitions for, 78; selfdisclosure example, 245; substance abuse issues for, 78, 279; why questions for, 232 advanced training support, by COS movements, 11 adversarial growth, 75; research application, 76 adversarial skills, 331–333, 333 advocacy efforts, 85, 112; in social work, 53; technology and, 45 advocacy skills, 112; for families, 392–395, 396 Advocates for Recovery through Medicine (ARM), 558

AFDC. See Aid to Families and Dependent Children affective expression, of families, 380 affirming, as joining method, 388 Affordable Care Act (Obamacare), Trump repeal threats on, 31, 35 African Americans: diversity sensitivity example of social worker, 137–139; LGBTQ intersectionality and, 128; northern migration of, 7, 12, 13; Progressive Era and, 6; self-help tradition of, 12; social institutions mistrust by, 118; social workers, 11, 12–13, 14, 137–139; values of, 117–118; women, intersectionality of, 128, 129 Africentric worldview, 117–118 age: self-awareness on, 130; social reality of, 124–126; stigma of, 124 ageism, 124; of LGBTQ, 125 agency: ahead of client, in client-social worker relationships, 500–502; code of ethics on termination policy of, 90–91; Critical Incident Analysis context of, 664, 672–673; family service, client mandated counseling example, 471– 472; individual assessment expectations of social worker and, 645; social work purpose in, 585 agency-based practice: goals versus client needs example, 475–478; group practice constraints in, 208–209; in public social welfare sector, 50–51; social workers challenges with, 50; termination policy, 90–91 agency function, in casework method, 18, 151 agenda building, in social work lobbying, 618 AIDS: duty to warn and, 97; health disparities for, 35; privileged communication example, 97–98

721

Aid to Families and Dependent Children (AFDC), 41 alcohol addiction, 31; example on, 84–86, 252–254; life stressors from, 84–85 Alcoholics Anonymous (AA), 556; boundary example and, 99–100; online sites for, 44 Alinsky, Saul, 574 altruism, 193 ambiguous communication, 392 ambivalence, of feelings, 240, 281 American Association for the Study of Group Work (AASGW), 20–21 American Association of Group Workers (AAGW), 21 American Social Science Association (ASSA), 6, 7 analysis and synthesis of information, as assessment task, 144 anecdotal data, 555, 556 anger management group, 424–425 animals, for supportive client relationships, 334, 362–363 Annual Social and Economic Supplement (ASEC), of Current Population Survey, 32 anticipatory empathy, 189, 560–561; adolescent truancy example, 181–182, 192–193; clients nonverbal communication, 188–189; detachment step in, 178; diabetes example, 177–180; diversity sensitivity example, 139–140; for endings, 514–515; environmental considerations and, 181; families example of, 191–193; gang violence example, 183; identification step in, 178; incorporation step in, 178; mandated clients and, 183–184; in organizational change entry phase, 595–596; in preparation helping process, 177–190; research on engagement and, 183–184;

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INDEX

reverberation step in, 178; social workers nonverbal communications, 185–188; terminal illness example, 180; TI practice and, 190 anti-immigration executive orders, of Trump, 31 anti-Japanese campaign, 16 anti-Muslim, Trump rhetoric of, 37, 39 ARM. See Advocates for Recovery through Medicine art activity group, 425 artistry, of social work, 47, 141, 185, 241 ASEC. See Annual Social and Economic Supplement Asian worldview, 119 ASSA. See American Social Science Association assertiveness, 343–344 assessment, 143; analysis and synthesis of information in, 144; client participation in, 3, 148; of clients life transitional stressors, 155–159; of clients strengths, 152–155; client verbal report for, 145; cultural competence and diversity sensitivity in, 147; deductive reasoning in, 145; depression example for, 145–148; eating disorder example, 153–154; family preservation program, 157–158; gang violence example, 154–155; inductive reasoning in, 145–146; information collection in, 144; level of fit and, 107–108; lifemodeled, 3, 148–152, 159; ongoing, 107; schizophrenia example, 326–327; social worker client observation, 145; stroke example, 148–152; tasks, 144–148; use of visual, 159–161, 160. See also family assessment; individual assessment Association of Social Work Boards (ASWB), 49 asylum seekers, 37

INDEX

|

722

attachment, 105–107 authority structure: in client-social worker relationships, 472–475; in organizations, 583–584 autism spectrum diagnosis, 296–300 automation, global economy impacted by, 38 autonomy, 52; in adolescence, 57; Ethical Principles Screen on, 92; group member, 442 avoidance: direct address of client, 233; facilitating skills on, 280–283; group practice illustrations on, 449–451; internal mediating skills for, 444; prostrate cancer example, 486–487, 498; residential treatment facility example, 513–514; substance abuse example, 282–284; of why questions, 232; youth diversion program example, 282–284 avoidance separation phase, 516, 521–522, 527; dependent client example, 517–519; intern therapeutic alliance example, 517–519; long-term care facility example, 519–520; social worker reluctance example, 517–519 background data: in family assessment, 647–648; in group assessment, 650; in individual assessment, 643–644 Bandler, Bernard, 82–83 bargaining, as consensus or conflict strategies, 570 Bateson, Gregory, 23 Beck Depression and Anxiety Inventories, 169–170 beginnings, in helping process: activity use, 246–247; client feelings understanding, 237–241, 248; degree of choice in, 217– 224, 224; depression example, 225; with families, 251–257, 252; with groups, 252, 255–257; information collection, 229–237; intellectual disability example,

225–226; marital problems example, 226; professional use of self, 241–246; purpose, role, feedback explanation in, 225–229; schizophrenia example, 226–227; trauma-informed, 248–251; working agreement establishment, 247 behavioral challenges, from stress, 68, 69 behavioral change, groups for, 196, 197 behavioral feedback: adolescence substance abuse example, 269; adult substance abuse example, 269–270; exploring and clarifying skills for, 269–270 behaviorally challenged children, 59–60 behavioral problems, from stress, 68 behavioral rehearsals, 325 behavioral therapy, 22 bereavement, self-disclosure example for, 243–244 bereavement group, 174; mutual aid and, 289–292. See also group assessment, of bereavement group Bertalanffy, Ludwig von, 24 binary notions, of gender, 121 Black Lives Matter protest, 32, 579 blended family, 369, 376, 412–418 bottom-up approach, for communities, 553–554 boundaries: AA example, 99–100; diffuse family, 370; dual relationships and, 98–99; in online counseling, 89–90; permeable family, 370; rigid family, 370; violations of, 98–100 boycotts, as consensus or conflict strategies, 574 breast cancer group example, 200 Breckinridge, S., 28 brief introduction, in Record of Service sample, 657 Brief Symptom Inventory, 170 Bronfenbrenner, Urie, 55 built and natural environments, of client, 333–334, 358

723

bullying: of intellectual disabled, 126; of LGBTQ child and adolescent, 123 Bush, George W., 42 Campbell Collaboration, 49 CARF. See Commission on Rehabilitation Facilities case study method, 162 case summary, in Critical Incident Analysis, 672 casework method, 20; agency function in, 18, 151; Flexner and, 17; Reynolds and, 19 cause-function, 1, 30 CC. See Conference of Charities Census Bureau: Current Population Survey ASEC report on poverty, 32; on immigration, 36 Center for Immigration Studies, of Census Bureau, 36 challenges: attachment, in foster care, 106; community practice practical, 578–579; of cultural identity, 3; in endings helping process, 538; ethical, 91–93, 95; of LGBTQ parenthood, transitions, 71–72; for medical social workers, 50; of social workers, in agencybased practice, 50; of social workers regulatory process interventions, 633; stress behavioral, 68, 69; technology, for social workers, 44; trauma long-term, 77 change strategies, for communities, 567; social activities example, 568–570 charitable choice clause, in PRWORA, 42 charity, settlement house movement distaste of, 8–9 charity organization societies (COS) movements, 7–8, 10, 82; advanced training support by, 11; community organization method and, 25; religion and, 8

|

INDEX

Chicago School of Civics and Philanthropy, 9, 14 Child Guidance Movement, 17, 23 Child Protective Services (CPS), mandated services example for, 512–513 children: animal connection for, 362–363; bullying of LGBTQ, 123; developmentally challenged, 198, 211; emotionally and behaviorally challenged, 59–60; families without, 369; lead exposure, 319; maltreatment of, 31; play for engagement with, 106; in poverty, 33. See also adolescence child sexual abuse (CSA), 249; countertransference example, 485; example, 336; groups example, 201–202; historical time example on, 63–64; individual time example on, 64–65; mandatory reporting example, 470–471; physical touch example, 187; practice outcomes example, 166–168, 171–172; priest, 66; RAI single-subject design, 167–168, 170, 172; shame and guilt for, 64; social time example on, 65–66; suggestions example, 275; trauma and, 77–78 child sexual abuse legislation illustration: information collection in, 627–628; legislators and personnel engagement, 628; Merryn and, 627–630; political context understanding and use in, 629; pressure maintenance in, 629–630; school-based prevention programs, 628; testifying in, 628–629 Chinese Americans, 16 Chinese Exclusion Act (1882), 16 clarification: exploring and clarifying skills for, 264–265; of indirect communication, 151, 158; NASW Code of Ethics on intern roles and, 229 client defenses, leukemia example, 488–490

INDEX

|

724

clients: abrupt departures of, 540–542; actions of, 3; animals for supportive relationships, 334, 362–363; assessment participation by, 3, 148; brief encounters, in endings helping process, 538–539; built and natural environments of, 333–334, 358; community outings for, 361–362; competence of, 342–344; cultural identity of, 116–129; decision-making of, 3; degree of choice of, 109–110, 217–224, 224; dependent, avoidance separation phase and, 517–519; direct address of avoidance by, 233; empowerment of, 53; feedback from, 233; feelings of, 237–241, 248; housing for cognitively impaired, 358–361; maladaptive interpersonal processes between social workers and, 469–508; nonverbal communication, 188–189; practice interventions evaluation by, 3; privilege and disenfranchisement of, 132; social isolation of elderly, 338–340; social reality of, 115, 116–129; spatial needs in environment and organization, 334–335; strengths and limitations, in individual assessment, 645–646; strengths assessment of, 152–155; teacher mediation, practice illustration on, 350–351; verbal report, as data source, 144–145; victimization by injustice of, 20 client-social worker engagement: activity use for, 246–247; client feelings understanding, 237–241, 248; core skills for, 224–257; in families and groups, 251–257; feedback for, 225–229; mandated clients purpose and role explanation, 227–228; professional use of self for, 241–246; purpose and role explanation for, 225–229; relevant information collection for, 229–237;

skills for, 248; in TI practice, 248–251; working agreement establishment for, 247 client-social worker relationships: attachment and, 105–107; empathy in, 104; engagement in, 105; ethical practice for, 103–104; as fiduciary, 88; life stressors and, 107; maladaptive interpersonal processes of, 469–508; partnership in, 3, 132, 154, 229; schizophrenia example, 104; technology and dual, 45; trust establishment in, 105; victim assistance program example, 105 client-social worker relationships, maladaptive patterns in, 469; agency goals versus client goals, 475–478; client defenses, 488–490; countertransference, 482–485; expectation differences, 478– 480; interpersonal control in, 480–482; interpersonal obstacles sources, 470, 490, 498–499; practice context and accountability, 470–471; social work methods and skills, 493–500; taboo concerns, 486–487; TI considerations, 491–492, 493; transference, 482– 485; worker authority, power and socialization, 472–475 client-social worker relationships practice illustrations: of agency ahead of client, 500–502; on client recontract, 505–508; common heritage use, 502–505 climate change, deep ecology and, 80 Clinton, Bill, 41, 42 closed-ended questions, 230–231 COA. See Commission on Accreditation coalition-building, in social work lobbying, 618, 625, 631, 638–639 coconstructing cooperation, with mandated clients, 240–241 code of ethics: agency termination policy example, 90–91; of International

725

Association for the Advancement of Social Work Practice with Groups, 88; of International Federation of Social Workers, 88 Code of Ethics, of NASW: on community and neighborhood empowerment, 547; on intern roles and clarifications, 229; on privacy violation, 95; purpose of, 87–88; values incongruence and understanding of, 101; whistleblowing and, 609 coercive power, 67 cognitive beliefs, stress and, 68 cognitive functioning, stress impact on, 68 cognitively impaired client, housing for, 358–361 collaborating skills, 323–328, 329, 333, 350–351, 493, 566 collaboration, in organization engagement, 603–604, 610 collaborative approaches, to community practice, 547 collective action: in community practice, 550–553; for consensus or conflict strategies, 574–575 collective change strategies: consensus and conflict, 570–578, 575; costbenefit analysis for, 573, 575; ethical considerations for, 575, 579–680 collectivism: in Asian worldview, 119; in Latino worldview, 118 Colored Woman in a White World, A (Terrell), 13 Columbia University Evidence-Based Practice and Policy Online Resource Center, 49 Columbia University School of Social Work, 11 Commission on Accreditation (COA), 632 Commission on Rehabilitation Facilities (CARF), 632

|

INDEX

commitment, facilitating skills challenging of, 281–282 common heritage approach, in diabetes example, 502–505 common stressors, groups for, 196, 197, 198 communication: adaptive, 379–380; ambiguous, 392; clarification skills, 264–265; cultural traditions and, 147–148; double-bind, 377–378; exploring and clarifying skills for clarification of, 264–265; of families, 377–380; genuine, 185; incongruence in, 146, 377; indirect, 146, 151, 158; internal mediating skills for improving, 392; metacommunication, 378; privileged, 88, 96–98; verbal, 144–145; worldview of, 117. See also nonverbal communication communities, 578–580; bottom-up approach for, 553–554; change strategies identification and implementation, 567–570; clients outings in, 361–362; consensus or conflict strategies use, 570–578, 575; criminal justice system example, 575–578; discrimination as stressor in, 546; functions of, 546; hospital methadone maintenance program in, 555–559; Latino values of, 118; life stressors in, 547; methods and skills for, 103; modality, social workers use of, 545; NASW Code of Ethics on empowerment in, 547; nonlocale, 546; as protective factor, 74, 75; resource mobilization in, 85; social problems in, 69; stressors for, 546–547; terminology of, 546; top-down approach, 553; urbanization of, 5, 7 community members: collective action, 550–553; identification and recruitment, 556–559; stake development, 562–563, 567; structure creation, 563–566, 567

INDEX

|

726

community mobilization, 556–557; critical consciousness development, 559–562; motivation enhancement, 559, 567 community needs and strengths assessment, 567; bottom-up approach, 553–554; information collection in, 554–555; top-down approach, 553 community organization method: concepts of, 26–27; on locality development, 26; process emphasis of, 26; settlement houses and COSs impact on, 25; on social action, 27; social change goals of, 26; on social planning, 26–27 community practice, 2; collaborative approaches in, 547; locality development in, 548, 551; practical challenges for, 578–579; radical approaches to, 547; social action in, 548, 551; social planning in, 548, 551; TANF, VNA, RCRG example, 551–553 compassion fatigue, 491, 493 competence, of client, 342–344. See also cultural competence competition, worldview of, 116 compliance, organizational engagement and refusal of, 508 concrete services, 582 Conference of Charities (CC), 6 confidentiality: in ethical practice, 88; Ethical Principle Screen on, 92; mandated reporting and, 93; in online counseling, 89 Confidentiality of Alcohol and Drug Abuse Patient Records Act (1987), 94 conflict, in organization engagement: action implication, 608–609; compliance refusal, 608; group action, 608; polite disobedience, 607–608; whistleblowing, 609 conflict and disagreement: in families, 380–381; of group member, 442–443, 458–459. See also consensus or conflict strategies

connectedness, in families, 381–382 connecting method, for groups, 440 connecting skills, 562 consecutive transactions, in Record of Service instrument, 658–661 consensus or conflict strategies: Alinsky on, 574; bargaining, 570; boycotts, 574; case example for, 575–578; collective action for, 574–575; coordinated public action, 572–574; demonstration, 574; example for, 575–578; negotiating, 571; protest, 574; sit-ins, 574 contemplation stage of change, 156 content and context, in independent variable, 164, 165 control group, 163 cooperation: coconstruction, by solutionfocused questions, 156; group skills for mutual support and, 440; mandated clients coconstructing of, 240–241 coordinated public action, as consensus or conflict strategies, 572–574 coordinating skills, 111–112, 321–323, 329 coping, 56, 73; environmental resources for, 2, 69–70; of families with death example, 365–367; internal resources for, 69; research findings, 70–72. See also life stressors-stress-coping paradigm coping questions, 154–155, 272 Corcoran, K., 170 COS. See charity organization societies cost-benefit analysis, 573, 575 Council on Social Work Education (CSWE): on administration and supervision education, 28; MSW program and social work licensing, 49; national curriculum study of, 28; regulatory context for, 632 countertransference, 482–484; CSA example, 485

727

court hearing, role-play example of, 324–325 court-mandated clients, 217–218 COVID-19 pandemic, 32, 579, 683n1 CPS. See Child Protective Services criminal justice system, communities and, 575–578 critical consciousness development, in community mobilization, 559–562 Critical Incident Analysis: agency context in, 664, 672–673; case summary, 672; group development phases in, 665–666; group formation in, 663–664; helping steps in, 672, 677–678; incident context, 666–667, 674–675; level of fit in, 665–666, 673–674; life stressors defined in, 665, 673; life stressors presentation, 671, 677; mutuality about focus and role expectations in, 664–665, 673; practice analysis, 667–671, 675–676; practice monitoring in, 161, 162; social and normative structures in, 665–666; social and physical environments in, 665–666; theoretical concepts and research findings, 672, 677 critical race theory, 129 CSA. See child sexual abuse CSWE. See Council on Social Work Education cultural competence, 114; assessments and, 147; considerations for, 137; diversity sensitivity and, 2–3, 115, 147; examples, 137–142; meaning of, 115–116; nonverbal communication and, 147; self-awareness and, 130 cultural humility, 135–136 cultural identity, 261; of clients, 116–129; self-awareness in, 130; of social workers, 130–136; values, traditions, challenges of, 3 cultural traditions, communication and, 147–148 culture, 1, 3; family, 382

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INDEX

Current Population Survey, ASEC on poverty, 32 curriculum: administration and supervision social work, 28; CSWE national study on, 28; group, 430–431; group work method, 20–21 Darwin, Charles, 7; on human development, 54–55 data: anecdotal, 555, 556; breaches, 44–45; collection, in settlement house movement, 9; on poverty, 32. See also background data data sources: client verbal report, 144–145; social worker observation of nonverbal communication, 145, 146 death, 212, 265; family coping example, 365–367; infant mortality, 69; loss of loved one gender differences, 122; monopolization in group example, 432–434; stress from, 68 decision makers persuasion, in social work lobbying, 620 decision-making: of clients, 3; professional values incongruence and, 101 deductive reasoning, in assessment, 145 deep ecology, 79; climate change and, 80; networks interdependence in, 2, 80; physical environments and, 80, 81; principles of, 80–81; selfcorrecting feedback loops in, 2; social sustainability and, 80 deep poverty, 33; power relationships and, 62 defenses, client, 488–490 defensiveness, group practice illustrations on member, 453–456 degree of choice, 109–110; mandated services, 217–222; services offered, 222–223, 224; services sought, 224 demonstrating method, in organizations engagement, 601–603, 610

INDEX

|

728

demonstration, as consensus or conflict strategies, 574 denial, 266; group practice illustration on pregnant adolescents and, 451–453 dependent variable, 163–164 deportation of immigrants example, 330, 332 depression: of adult survivors of sexual abuse, 78; assessment example on, 145–148; helping process beginnings example, 225; organic and situational, 145; relevant information collection example, 229–230; stroke example and, 150 deregulation, 30 detachment step, in anticipatory empathy, 178 determination stage of change, 156, 158 developmentally challenged children: group example for, 198; periodic assistance for, 211 Dewey, John, 9, 20 diabetes: anticipatory empathy example, 177–180; common heritage approach example, 502–505; summarizing example, 233–234 Diagnostic and Statistical Manual for Mental Disorders (DSM V), third-party payment and, 52 differentiating method, in groups, 443; differing opinions and perceptions support, 443; member autonomy and individuality, 442; member disagreement, 442–443, 458–459; member work credit, 443 differentiating skills, 562 difficult life transitions, 112, 174 diffuse family boundaries, 370 directing group skills, 440 disability: intellectual, 126, 225–226; physical, 125, 126, 129, 148–152; social reality of, 124–126

discomfort: creation and management, in organization, 596, 598–600; facilitating skills and, 283–284 discrepant messages, 230; exploring and clarifying skills for identification of, 266; identification of, 266 discrete tasks, 171 discrimination, 87, 136; as community and neighborhood stressor, 546; against LGBTQ, 123; mental illness and, 125–126; physical disabilities and, 126 disenfranchisement: social worker privileged position and, 132; socioeconomic status and, 128 disengagement, in endings helping process, 535–537 disobedience, organizational engagement and polite, 607–608 dissociation, 266 divergent views exploration, 392 diversity, 2, 3; human and environmental, 62, 63; of social network, 136–137; in social workers personal lives, 136–142 diversity sensitivity, 114; adult survivors of childhood trauma example, 141–142; African American social worker example, 137–139; anticipatory empathy example, 139–140; in assessments, 147; considerations for, 137; cultural competence and, 2–3, 115, 147; examples, 137–142; generalizations and, 115; LGBTQ example, 140–141; process of, 116; self-awareness and, 130; stereotypes and, 115; teen parents outreach program example, 137–139 division of labor, in organizations, 584 domestic terrorism, 39–40 domestic violence, 78, 105; intersectionality of African American victims of, 129; professional socialization example, 473–475; structured group meeting in,

729

424; trauma examples, 240, 249, 250, 470–471 dosage, in independent variable, 164, 165 double-bind communication, 377; triangulation and, 378 drug addiction. See substance abuse DSM V. See Diagnostic and Statistical Manual for Mental Disorders dual relationships: boundaries and, 98–99; mandated clients and, 218; in online counseling, 89–90; technology and, 45 Dubos, René, 55 duration, of group sessions, 204–205 duty to warn: AIDS and, 97; Reamer on, 94; statutory laws on, 93–94; Tarasoff v. Regents of the University of California case and, 94 Dynamic Administration (Follett), 27 Earned Income Tax Credit (EITC), 40 earned privilege, of social workers, 132 eating disorder, 153–154 ecofeminism, 2, 81 ecological degradation, 2 ecological perspective: adversarial growth, 75, 76; assumptions of, 55–56; deep ecology, 2, 79–81; ecofeminism, 2, 81; environmental stressors and, 59–60; habitat and niche, 2, 55, 61, 67, 100; on human development, 54; level of fit, 58–60; life course, 2, 62–66, 67; life stressors-stress-coping-challenge, 67–70, 73; person:environment fit concepts, 1–2, 56–58, 60, 73–74; power and powerlessness, 61–62, 67; reciprocity of relationships and transactions, 56–58; resilience and protective factors, 73–74, 75; stress and coping research findings, 70–72; trauma and life course, 77–79 ecomaps, 3, 160, 160–161 economic development policies, 615

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INDEX

education: anger management group example, 197–198; COS advanced training support in, 11; elderly day program example, 198; groups for, 196–198; progressive movement in, 20, 21; reformers, of Native Americans, 15; settlement house movement support by, 9; social work, 27, 30. See also Council on Social Work Education; individualized educational plan EITC. See Earned Income Tax Credit elderly client: ageism and, 124, 125; assisted living sexual activity example, 332; food delivery program for, 139; food service practice illustrations, 344–346; group scapegoating example, 435; social isolation of, 338–340; SSC organization physical space, 317–318; time-limited groups for substance abuse of, 203 electoral politics: political campaigns work, 640; social justice through political engagement, 641–642; social workers in, 640–641 emergency services, 215 emotional problems, from stress, 68, 69 empathy: in client-social worker relationship, 104; core skills for, 237–239; demonstration of, 184–185; demonstration skills, 189; legitimizing and, 239–240; in preparatory phase, 108; skills, for feelings, 237–238; universalizing and, 239–240; verbalizing and, 239. See also anticipatory empathy empowerment, 3, 343–344; of clients, 53; of communities and neighborhoods, 547; group practice illustrations on feelings and, 465–468; groups and, 193; of rape victim, 348–350 enabling skills, 263, 263 ending phase, of life-modeled practice, 3, 112–113

INDEX

|

730

endings, in helping process: client abrupt departures, 540–542; disengagement, 535–537; future plans development, 534–535; on gains and remaining work, 529–534; mandated time limits for, 539–540; premature termination, 509–510; preparation for, 510–515, 515; separation phases, 516–529, 527; service evaluation, 537–538; variations and challenges in, 538; worker and client brief encounters, 538–539 engagement: children play for, 106; research on anticipatory empathy and, 183–184. See also client-social worker engagement engagement, in organizations: collaboration and, 603–604, 610; conflict and, 607–609; creating conflict method, 610; demonstrating method, 601–603, 610; implementation and institutionalization, 609–613; persuasion in, 604–607, 610 entry phase, for organizational change, 594, 600; anticipatory empathy in, 595–596 environmental conditions, groups for, 195–196 environmental diversity, 63 environmental forces, for organizational change, 591, 604 environmental pressures, 84, 110 environmental resources: for coping, 2, 69–70; as protective factor, 74, 75 environmental strengths and limitations, in Record of Service sample, 658 environmental stressors, 174, 320; for emotionally and behaviorally challenged children, 59–60; physical environment, 59–60, 315–319; social environments, 310–315; social work methods and skills, 319–337

environmental stressors practice illustrations: organizational stressors, 342–364; social network stressors, 337–342 environmental supports and obstacles, in individual assessment, 646–647 environments: anticipatory empathy and, 181; Bronfenbrenner on, 55; client fit with built and natural, 333–334, 358; clients spatial needs in, 334–335; human development affected by, 55. See also physical environments; social environments environments practice illustrations: elderly client social isolation, 338–340; family reconnection, 337–338; on organizations stressors, 342–364; sexual orientation and role-play, 340–342; on social networks, 337–342 environment transactions, in bereavement group assessment, 655 episodic services, 215 equality, Ethical Principles Screen on, 92 equity-enhancing policies, 615 E-therapy, 44 ethical challenges, 91–93; Reamer on, 95 ethical practice, 2; boundary violations, 98–100; for client-social worker relationships, 103–104; for collective change strategies, 575, 579–680; confidentiality in, 88; core values of, 86; informed consent in, 88–89, 557; legal mandates and, 88, 93–96, 217–218; for mandated clients, 219; medical technology moral and, 43; for online counseling, 89–90; on privileged communication, 88, 96–98; for substance abuse client, 90–91 Ethical Principles Screen, 91–93, 93 ethnicity: self-awareness on, 130; social awareness of, 130; social reality of, 117–120. See also race

731

evaluation: of practice outcomes, 3; service, in endings helping process, 537–538. See also practice evaluation evidence-guided practice, 46–47; practice monitoring in, 161–162 exceptions, solution-focused questions on, 153, 272 exchanges, 60 executive family system, 371, 372–373 executive power, Trump abuse of, 61 experiences: exploring and clarifying skills for meaning of, 265–266; skills for meaning of, 265–266 experimental group, 163 exploitative power, 67 exploring and clarifying skills, 110, 263, 271; for behavioral feedback, 269–270; communication clarification, 264–265; discrepant messages identification, 266; for experiences meaning, 265–266; for feedback, 269; focus and direction development, 264; hypothesis and, 268–269; patterns exploration, 267–268; puzzlement sharing, 265; for selfreflection, 270–271; suppressed feelings pursuit, 266–267 expressive techniques, guiding skills of, 277–278 extended family, 369; relationships in, 381 externalized stress, of men, 122 external organizational stressors: accountability demand, 582–583; sources and level of funding, 582 facilitating skills, 111, 284; for ambivalence feelings, 281; on avoidance, 280–283; commitment challenging, 281–282; discomfort and, 283–284; discrepant messages response, 281 faith-based services (FSB), 43; PRWORA charitable choice clause, 42

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INDEX

fake news, 45 families, 2; affective expression of, 380; anticipatory empathy example of, 191–193; case example of, 255–257; communication of, 377–380; conflict and disagreement in, 380–381; coping with death example, 365–367; development, worldview, transformation, 383–386; environments practice on reconnection of, 337–338; extended family relationships, 369, 382; first-order life issues in, 384–385; helping process beginnings example, 251–257, 252; helping process work with, 191–193, 251–257, 252; internal mediating and advocacy skills, 392–395, 396; intrafamilial dynamics, 191–192; joining methods and skills for, 388–391, 391; key terms and concepts of, 387; Latino values of, 118; LGBTQ response by, 124; maladaptive interpersonal processes in, 365–418; methods and skills for, 103, 251–252, 252; myths and secrets of, 379–380, 392, 406–412; process of, 376–377; as protective factor, 74, 75; second-order stressors in, 384–385; separateness and connectedness in, 381–382; statistics on, 367–368; traditions and rituals in, 383, 389; transactions, 57 families practice illustrations, 396; on blended family, 412–418; couple relationship strengthening, 402–406; parent-child relationship enhancement, 397–401; TI practice on family secret, 406–412 family assessment: background data, 647–648; family patterns for, 648–649; level of fit, 650; life stressors defined, 648; plans for, 650 family boundaries, 370–371

INDEX

|

732

family culture, 382 family dislocation, 31 Family Educational Rights and Privacy Act (FERPA) (1974), legal mandates and, 94 family forms: blended family, 369, 376, 412–418; without children, 369; extended family, 369, 382; nuclear family, 368; single parent, 361, 368–369 family functions: coping with death case example, 365–367; described, 368 family method: on intrafamilial processes, 24; Minuchin structural approach to, 24–25; Richmond on, 23; systems theory and, 24 family modality, 211–212; selection of, 214 family patterns, in family assessment, 648–649 family preservation programs, 333; assessment, 157–158 family secret, 392; adaptive communication example, 379–380; TI practice on, 406–412 family service agency, client mandated counseling example, 471–472 family structure, Minuchin on, 369–370 family subsystems: executive system, 371, 372–373; functioning in, 375–376; Minuchin on, 371–376; parent-child system, 371, 375; partner system, 371–372; sibling system, 371, 374 fatalism, in Africentric worldview, 118 federal government, 41; poverty rate and, 40; regulations standards of, 630, 632; Trump reduction of role of, 32 Federal Register, regulatory context and, 630 Federation of Colored Women’s Clubs, 13 feedback: in beginnings helping process, 225–229; behavioral, 269–270; from clients, 233; for client-social worker engagement, 225–229; exploring

and clarifying skills for, 269; on life stressors, 73; negative and positive, 2; self-correcting feedback loops, 2 feelings: acknowledgment and verbalization of, 151, 239; ambivalence of, 240, 281; empathy skills for, 237–238; expression of strong, 444–445; group practice illustrations on empowerment and, 465–468; legitimizing and universalizing, 239–240; management examples, 277– 278, 286; negative, in ending separation phase, 516, 522–525, 527; reaching for specific, 151, 158; self-disclosure and, 238; suppressed, 266–267; thinkingfeeling-doing connection, 262, 267, 287–289; TI practice management of, 286; understanding of client, 237–241, 248 feminist movement, 120 feminist theory, 81, 120–121 feminization of poverty, 33 FERPA. See Family Educational Rights and Privacy Act fiduciary relationship, of client-social worker, 88 first-order life issues, 384–385 Fischer, J., 170 Flexner, Abraham, 17 flooding, in TI practice, 250 Floyd, George, 32, 579 focus and direction development, exploring and clarifying skills for, 264 Follett, Mary Parker, 27 force-field analysis, 3, 591, 680–681 form, in independent variable, 164, 165 foster care: art activity group for, 425; attachment challenges in, 106; family connections example, 337–338; parenting group, 79; suppressed feelings example, 266–267 foster child: placement decision, 353–355; self-advocacy skills of, 346–348

733

Frazier, E. Franklin, 14 freedom, Ethical Principles Screen on, 92 free trade zones, 37–38 frequency, of group sessions, 204–205 Freud, Sigmund, 17–18 FSB. See faith-based services full disclosure, Ethical Principles Screen on, 92 funding: homeless legislative example, 572–574; private, 630; public, 582, 630; sources and level of, 582 future orientation, worldview on, 117 future plans development, in endings helping process, 534–535 gains, endings helping process on, 529–534 Gamblers Anonymous, online sites for, 44 gang violence, 31, 69; adolescent stages of change example, 220–222; anticipatory empathy example, 183; assessment example of, 154–155 gender: adolescence mental health and, 122; binary notions of, 121; differences, 122; diverse, 121; identity, 120–124, 130, 134; neutral, 121; role, 121, 122; selfawareness of, 130; sensitivity, 121, 123. See also male; women gender-based perspective, 120, 124, 134; expectations in, 121–122; gender sensitivity in, 121, 123; on mental health, 122–123; self-awareness in, 130; sexism in, 121; terminology in, 121 genderfluid, 121 generalizations, 115 genograms, 3, 161 genuine communication, 185 Germain, Carel, 55 global economy, 37–38 global environments, 63 Global Severity Index, 170 goal attainment scaling, 168, 170–171, 172

|

INDEX

graphic representations: ecomaps, 3, 160, 160–161; force-field analysis, 3, 591, 680–681; genograms, 3, 161; social network maps, 3 grassroots efforts, technology and, 45 Gray, Freddie, 575–578, 579 Great Depression, 18, 19, 25 Great Society, 30 grief counseling, 79, 275; group example, 200–201; physical touch example, 187 group assessment, of bereavement group: background data in, 650; compositional balance in, 651–653; environment transactions, 655; group development phases, 655; interaction, friendship, and role patterns in, 653–654; mutual agreement of, 653; next helping steps, 655; normative and sanctioning patterns in, 654–655; temporal arrangement, group size, and space for, 650–651 group comparison method: control group in, 163; dependent variable in, 163; experimental group in, 163; independent variable in, 162–165; validity and reliability in, 163 group composition, 202; heterogeneous, 199; homogeneous, 199; Noah’s Ark principle for, 201 group development phases, in Critical Incident Analysis, 665–666 group formation, in Critical Incident Analysis, 663–664 group modality, 211, 214 group practice illustrations: on avoidance and recontracting, 449–451; on feelings and empowerment, 465–468; on group conflict, 456–459; on mandate resistance, 462–464; on member defensiveness, 453–456; monopolization addressed, 459–462; on pregnant adolescents and denial, 451–453; on scapegoating, 434–436, 446–449, 464–465

INDEX

|

734

groups, 2; adolescent residential treatment rap, 426; agency constraints on practice of, 208–209; anger management, 424–425; beginnings helping process with, 252, 255–257; for bereavement, 174, 289–292, 650–654; breast cancer example, 200; common focus for, 254–255; community resource example, 198; CSA example, 201– 202; curriculum misuse example, 430–431; empowerment and, 193, 465–468; for environmental conditions, 195–196; grief counseling example, 200–201; helping process work with, 193–210; leadership in, 206–207; life transitions assistance through, 194–195; maladaptive interpersonal processes in, 419–468; mandated clients substance abuse example, 252–254; member disagreement in, 442–443, 458–459; methods and skills for, 103; modality of, 211, 214; mutual aid from, 193–194, 251, 419; professional tasks in formation of, 210; as protective factor, 74, 75; purpose of, 194–196; renegotiation in, 198; resilience from, 193; responsive organizational climate of, 207–208; social action focus of, 197, 198; social and physical environments and, 195; for social development, 196, 197; for trauma, 195; universality and, 193; youth diversion program example, 201–202 groups, maladaptive communication and relationships in, 446–468; differentiating method, 442–443; group curriculum misunderstanding and misuse, 430–431; group development phases, 420, 421–422; group formation tasks, 423–425; internal group difficulties behavioral expressions, 431; internal mediation method, 443–445,

445; internal stress sources of, 423, 431; member roles in, 431–439, 439; methods and skills, 440–445; mutual aid and, 419, 425–427, 442; rules misuse and norms misunderstanding in, 427–429; social worker and, 439–445 group skills, 442; activities and programs use, 442; common themes identification, 441; connecting method, 440–442; contributions support, 440; cooperation and mutual support encouragement, 440; individual and group connection, 441–442; on member reactions, 440–441; member transactions directing, 440; participation encouragement, 441; scanning, 440 group structure: open-ended and ongoing, 203–204; physical setting, 206; sessions frequency and duration, 204–205; size, 205–206; temporal arrangement, 202–203; time-limited, 203–204 group types: for behavioral change, 196, 197; for common stressors, 196, 197, 198; for education, 196–198; for social change, 196, 197, 198; for social development, 196, 197; for task accomplishment, 196, 197 group work method: AAGW, NASW and, 21; curriculum, 20–21; functions of, 21; Schwartz and, 22; social goals model, 21–22; Vinter and, 21–22 guiding skills, 111, 280, 493; for activity engagement, 277; of expressive techniques, 277–278; homework assignment, 279–280; misinformation correction, 274; relevant information provided by, 274; through roleplay, 278; suggestions and advice of, 275–277; for task completion, 278–279; visualizations, 274–275 guilt, for CSA, 64

735

habitat, 2, 55, 61, 67, 100 Haley, Jay, 23 Haynes, George, 14 health clinic, 589 health disparities, 683n1; for AIDS, 35; for people of color, 34–36; poverty and, 34–36 Health Insurance Portability and Accountability (HIPPA) (1996), 94 Health Maintenance Organization Act (1973), 52 hearings, regulatory process organization of, 634–635, 637 helping process, 173–175; beginnings in, 217–257, 252; endings in, 509–542, 527; families work in, 191–193, 251–257, 252; groups work in, 193–210; preparation in, 177–216; truancy activity use in, 247 helping steps: in Critical Incident Analysis, 672, 677–678; in Record of Service sample, 661 here and now self-disclosures, 242 heritage pride, in Latino worldview, 118 heterogeneous groups, 199 heteronormative sexual identity, 123 heterosexism, 123; social privilege of, 134–135 hierarchical male domination, 2 hierarchical orientation, in Latino worldview, 118 HIPPA. See Health Insurance Portability and Accountability Hispanic. See Latino historical development, of social work, 1; COS movement, 7–8, 10–11, 25, 82; current practice, 45–53; historical trends 1900-2019, 29–30; people of color, 11–17; professionalization, 17–29; Progressive Era, 5–8; settlement house movement, 7–10; societal context, 30–45

|

INDEX

historical time, in life course, 67; CSA example, 63–64 historical trends, 1900-2019: causefunction, 1, 30; methodological divisions, 29–30 Hollis, Florence, 19 homeless, 31, 212, 246, 331, 555, 579; case examples, 101–102, 321–322; interns group work experience with, 208–209; legislative funding example, 572–574; LGBTQ adolescent example, 186–187; organizational stressors practice illustration on, 351–353; values incongruence in mother pregnancy example, 101–102; veterans, 78, 301–303 home visits, by social workers, 59–60 homework assignments, 279–280, 393 homicide, 69 homogeneous groups, 199 homophobia, 123; internalized, 124 hospital methadone maintenance program, 555–559 housing, for cognitively impaired client, 358–361 Hull House, 9 human development, 2; Darwin on, 54–55; ecological perspective on, 54; environment affect on, 55; life course concept of, 2 human diversity, 62 human service regulatory bodies, for JCAHO, CARF, COA, 643 humility, of social workers, 131, 135–136 Hurricane Katrina: PTSD and, 70; research findings on, 71 Hurricane Sandy, protective factors and, 76–77 hypothesis: exploring and clarifying skills and, 268–269; juvenile delinquency example, 268–269

INDEX

|

736

ICE. See Immigration and Customs Enforcement Ida B. Wells Club, 13 IDEA. See Individuals with Disabilities Education Act identification and recruitment, of community members, 556–559 identification step, in anticipatory empathy, 178 IEP. See individualized educational plan Illegal Immigration Reform and Immigrant Responsibility Act (IIRIRA) (1996), 42 illness, social reality of, 124–126 immigrants: asylum seekers, 37; deportation example, 330, 332; lawful permanent residents, 36; legal, 36, 110; refugees, 37; Trump on, 37; undocumented, 37 immigration, 37; Census Bureau on, 36; of Chinese Americans, 16 Immigration Act (1917), 16 Immigration and Customs Enforcement (ICE), 330, 332 implementation and institutionalization: in-service training for, 612; in organization engagement, 609–613 incarceration, of people of color, 31, 33 incident context, in Critical Incident Analysis, 666–667, 674–675 income inequality, poverty and, 34 incongruence, in communication, 146, 377. See also values incongruence incorporation step, in anticipatory empathy, 178 independent variable, 162–163; form, content, dosage, context and, 164, 165 indirect communication, 146; clarification of, 151, 158 indirect trauma: compassion fatigue, 491, 493; examples, 492; secondary traumatic stress, 491, 493; vicarious, 491, 493

individual assessment: agency and worker expectations, 645; background data in, 643–644; client strengths and limitations, 645–646; environmental supports and obstacles, 646–647; level of fit, 647; life stressors defined, 644–645; physical environment of, 646–647; plans for, 647; social environment of, 646 individual characteristics, as protective factors, 74 individualized educational plan (IEP): regulatory process challenges for, 633–634; regulatory process practice example, 636–640; team, 636, 638, 685n2 individual modality, 210–211 Individuals with Disabilities Education Act (IDEA) (1973), 636 individual time, in life course, 64, 67 inductive reasoning, in assessment, 145–146 industrialization, 5 inequality: Ethical Principles Screen on, 92; poverty and income, 34 infant mortality, 69 influencing skills, 112 information: guiding skills for relevant, 274; TI practice provision of, 285 information collection: anecdotal data for, 555, 556; as assessment task, 144; avoidance addressed, 233; in beginnings helping process, 229–237; closed-ended questions, 230–231; in community needs and strengths assessment, 554–555; in CSA legislation illustration, 627–628; interviews, 555–556; nonverbal communication, 229–230; paraphrasing, 231–232; rephrasing and, 151, 231–232; silence in, 233–235; in social work lobbying, 618, 627–628, 631; structuring questions, 231; surveys, 555; verbal encouragers, 229

737

informed consent, 88, 557; exceptions to, 89; in online counseling, 89 initial phase, of life-modeled practice, 3, 109–110 innovating skills, 112 innovation, institutionalization of, 612 in-service training, 612 institutionalized ageism, 124 institutional racism, of people of color, 32–33 integrated practice: modalities, methods, skills, 3, 102–103 intellectual disability: bullying and, 126; helping process beginnings example, 225–226; stigma of, 126 intellectualization, 266 interdependence of mind and body, in Asian worldview, 119 internalized homophobia, 124 internalized identity, of clients, 116–129 internalized stress, of women, 121 internal mediating skills, 112; for ambiguous communication, 392; avoidance and resistance challenging, 444; common perceptions identification, 445; for communication improvement, 392; divergent views exploration, 392; expectations renegotiation, 445; for families, 392–395, 396; family myths and secrets exploration, 392; in groups, 443–445, 445; homework assignment for, 393; maladaptive process transactional definition, 443–444; perceptions and behaviors legitimization, 392; of reflective comments, 393–395; reframing as, 392–393; for self- and other-awareness, 392; strong feelings expression, 444–445; of subsystems support, 393; for supportive demands, 393 internal organizational stressors: authority structure, 583–584; division of labor, 584

|

INDEX

internal resources, for coping, 69 International Association for the Advancement of Social Work Practice with Groups, 88 International Federation of Social Workers code of ethics, 88 interns: homeless group work experience, 208–209; NASW Code of Ethics on role and clarification of, 229; physical touch example, 188; therapeutic alliance and avoidance separation phase, 517–519 interpersonal forces, for organizational change, 592–593, 604 interpersonal stress, 196; social worker acknowledgement of, 494–495 intersectionality, 115, 136; of African American women, 128, 129; of LGBTQ African Americans, 128; multidimensionality of, 128; of Muslim HIV individuals, 128; overgeneralization and, 128; of physical disability, 129 interventions: effectiveness of, 47–48; Hollis on, 19; for substance abuse, 48 interviews, 555–556 intrafamilial dynamics, 191–192 Islam. See Muslim Islamic State, rise of, 39 Jackson, Don, 23 Jaffee v. Redmond (1996), 96 Jansson, B. S., 29 Japanese Americans, 16–17 JCAHO. See Joint Commission on Accreditation of Health Care Organizations jihad, Muslims and, 120 job loss, 38 joining methods and skills, 390–391, 391; affirming, 388; family worldview, rituals, myths, traditions respect, 389; therapeutic context as, 389; tracking and monitoring, 388–389

INDEX

|

738

Joint Commission on Accreditation of Health Care Organizations (JCAHO), 632 Judge Baker Guidance Clinic, 23 juvenile delinquency: anger management group for, 424–425; gender differences in, 122; hypothesis example, 268–269 juvenile justice system, 78–79 key players influencing, in social work lobbying, 618 labor and workforce, settlement house movements support of, 9 Latino (Hispanic) worldview: collectivism in, 118; family and community values of, 118; heritage pride in, 118; hierarchical orientation in, 118; on mental health, 118–119; on oppression, 119; women labor force exploitation, 129 lawful permanent residents, 36; TANF, SSI ineligibility for, 41–42 leadership, in groups, 206–207 lead exposure, 319 least harm, Ethical Principles Screen on, 92 Legal Defense Fund, of NASW, 609 legal immigrants, 36, 110 legal mandates, 88, 217–218; Confidentiality of Alcohol and Drug Abuse Patient Records Act and, 94; FERPA and HIPPA, 94; mandatory reporting example, 95–96; social workers on realms of, 93; statutory laws, 93, 95 legislation, 1, 614–615, 637–642; AFDC, 41; Chinese Exclusion Act, 16; Confidentiality of Alcohol and Drug Abuse Patient Records Act, 94; CSA, 627–630; FERPA and HIPPA, 94; Health Maintenance Organization Act, 52; IDEA, 636; IIRIRA, 42; Immigration

Act, 16; legislative process, 616–625; methods and skills for activity in, 103; Obamacare, 31, 35; political influence on, 85; PRWORA, 41, 42; Social Security Act, 28, 41; societal context of, 40–42; SSI, 41–42; TANF, 40, 41–42, 551–553, 632; USA PATRIOT Act, 42. See also legal mandates legislative advocacy, 29 legislative funding, homeless example, 572–574 legislative process: committee assignment, 617; legislation introduction, 616–617; legislative chambers presentation, 617–618; PACs and, 61; President or governor presentation, 618; social work lobbying, 618–625 legislators and personnel engagement: in CSA legislation illustration, 628; in social work lobbying, 618, 620–622, 628, 631 legitimizing, of clients feelings, 239–240 lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community, 31; African American intersectionality and, 128; ageism and, 125; children and adolescent bullying in, 123; discrimination against, 123; diversity sensitivity example, 139–140; family response to, 124; gender roles in, 122; homeless adolescent example, 186–187; mental illness stigma of, 129; parenthood transition research on, 71–72; parenting stigma for, 72; physical touch example, 188; sexual identity of, 123–124 leukemia, client defenses example, 488–490 level of fit, 3; adaptation and, 55; assessment and, 107–108; case example, 59–60; in Critical Incident Analysis, 665–666, 673–674; ecological perspective on, 58–60; in

739

family assessment, 650; in individual assessment, 647; in life-modeled assessment, 148; life stressors threaten to, 2; maladaptation and, 58; perceived and actual, 58; psychological, social impotence and, 58–59; social worker and improvement of, 59 LGBTQ. See lesbian, gay, bisexual, transgender, and queer/questioning life book example, for adoption, 477–478, 505–508 life course concept, 2; elements of, 62–63; historical time and, 63–64, 67; individual time in, 64, 67; social time in, 65–66; trauma and, 77–79 life-modeled assessment, 159; client participation in, 3, 148; level of fit in, 148; life stressors formulation in, 148; momentto-moment emphasis in, 151–152 life-modeled practice: Bandler on, 82–83; on client social and physical environment, 108; client-social worker relationship and, 103–104; client strengths, actions, decision-making in, 3; client-worker relationship in, 3; at community level, 543–544; culture in, 3; degree of client choice in, 109–110; diversity-sensitive and culturally competence in, 2–3, 115, 147; empowerment and social justice practice in, 3; ending phase of, 3, 82, 112–113; features of, 83; initial phase of, 3, 82, 109–110; integrated modalities, methods, skills in, 3, 102–103; knowledge-building contribution in, 3; life stories in, 3; ongoing assessment in, 107; ongoing phase of, 3, 82, 110–112; organizational, 586–613; at organizational level, 543–544; physical environments in, 3; at political level, 543–544; practice evaluation in, 3; preparatory phase of, 3, 82, 109;

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INDEX

professional function in, 2, 83–86, 86; social environments in, 3; social worker personal values and, 100–102 life-modeled practice monitoring: critical incidents, 663–678; Record of Service, 657–661 life stories, 3 life stressors, 56; from alcohol addiction, 84–85; in communities, 546–547; in communities and neighborhoods, 547; Critical Incident Analysis defining of, 665, 673; Critical Incident Analysis presentation of, 671, 677; family assessment definition of, 648; genderbased perspective on, 122; individual assessment definition of, 644–645; level of fit threatened by, 2; life-modeled assessment formulation of, 148; professional function and, 86; Record of Service sample identification of, 658; TI practice and past trauma, 303–309; transitional processes as, 258–261; white male protective function in, 129 life stressors-stress-coping paradigm, 67; client-social worker relationships and, 107; coping tasks for, 2; emotional stress, 2; feedback on, 73; Hurricane Katrina and, 70–71; on LGBTQ transition to parenthood, 71–72; life stressor, 68, 73; physiological stress, 2 life transitions, 84, 110; for adult survivors of sexual abuse, 78; assessment of clients, 155–159; difficult, 112, 174; early adolescence loss example, 260– 261; group assistance with, 194–195; past trauma and stigma of, 300–303 life transitions practice illustrations: autism spectrum diagnosis, 296–300; bereavement group and mutual aid, 289–292; sex education group, 292–296; thinking-feeling-doing connection, 287–289

INDEX

|

740

linear thinking, 57 lobbying, 61; on new and modified policies, 615–616; on regulations, 616. See also social work lobbying local environments, 63 locality development: community organization method on, 26; in community practice, 548, 551; rat infestation and, 548, 549–550 local standards, for regulations, 630, 632 long-term, open-ended services, 215 long-term care facility, avoidance separation phase example, 519–520 long-term challenges, from trauma, 77 loss of loved one, gender differences in, 122 MacDonald v. Clinger (1982), 96 maintenance stage of change, 156 maladaptation, level of fit and, 58 maladaptive communication and relationship patterns, 84 maladaptive interpersonal processes, 2, 174; client-social worker maladaptive patterns, 470, 480–482, 488, 498–499; in families, 365–418; within groups, 419–468; between social workers and clients, 469–508 male: hierarchical domination by, 2; identity, in Africentric worldview, 118; resilience and protective function of white, 129 managed care, 52 management, of feelings, 277–278, 286 mandated clients: adolescent gang violence example, 220–222; anticipatory empathy and, 183–184; coconstructing cooperation with, 240–241; courtmandated, 217–218; CPS example, 512– 513; dual relationships and, 218; ethical practice for, 219; purpose and role explanation for, 227–228; reservations of, 218–219; resistance from, 462–464; services for, 217–222, 471–472,

512–513; skills and considerations for, 222; solution-focused technique for, 156, 241; stages of change and, 220–222; substance abuse group example, 252–254; time limits for, 539–540 mandatory reporting, 249; CSA example of, 470–471; prenatal drug exposure example, 95–96; privacy and substance abuse, sexual abuse, 586–587; statutory laws on, 93 MAP. See Medical Assistance Program marijuana legalization, 632–633 marital problems, helping process beginnings example, 226 mass shootings, 78 Master of Social Work (MSW), social work licensing and, 49 master-slave caste system, for Mexican Americans, 15 Matthews, Victoria Earle, 13 Measures for Clinical Practice (Corcoran and Fischer), 170 mediating skills, 323–328, 329, 333, 350–351, 493, 566 Medicaid, 51, 632 Medical Assistance Program (MAP), 213 medical social workers: challenges for, 50; stroke example of, 148–152 medical technology, moral and ethical issues in, 43 Medicare Part B, 51, 213 member roles, in groups: indigenous leader, 436–437, 439, 453; monopolizer, 432–434, 439, 459–462; scapegoat, 199, 434–436, 439, 446–449; silent member, 431–432, 439; subgroups and alliances, 437–439, 439 mental health: adolescence gender and, 122; Africentric worldview of, 117; Asian worldview and, 119; genderbased perspective on, 122–123; gender differences in, 122; Latino worldview

741

of, 118–119; LGBTQ community and, 124; Native American worldview of, 120; services, 23; single-subject design example, 164–166; systems theory in services of, 24 Mental Health Research, from Science Daily, 49 mental hygiene movement, 17 mental illness: autism spectrum diagnosis, 296–300; day treatment program example, 432–434; depression, 78, 145– 148, 150, 225, 229–230; discrimination and, 125–126; eating disorder, 153–154; gender differences in, 122; LGBTQ stigma of, 129; mutual aid and, 364; oppositional defiant disorder, 220–222; periodic assistance for, 211; PTSD, 70, 336, 426, 560; schizophrenia, 23, 104, 226–227, 326–327; self-awareness on, 130; shame and stigma of, 125 Mental Research Institute (MRI), 23 Merryn, Erin, 627–630 metacommunication, 378 methodological divisions, 29–30 methods, 3 Mexican Americans: master-slave caste system for, 15; racism of, 15 microaggressions, 126–127, 136; examples of, 127, 137; power of, 127 microinsults, 127 microinvalidations, 127 migration, African Americans northern, 7, 12, 13 militant and radical Islam, 120 minimal verbal encouragers, 229 Minuchin, Salvador: on family structure, 369–370; on family subsystems, 371–376; structural family approach of, 24–25 miracle question, 156, 158, 167 misinformation: guiding skills for correction of, 274; TI practice correction of, 285

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INDEX

misuse, of power, 2, 55, 61 mobilizing skills, 110–111 modality, 3; community, 545; considerations example for, 212–213; factors, for ending, 510–512, 515; of groups, 211, 214; in integrated practice, 3, 102–103. See also practice modality moment-to-moment emphasis, in lifemodeled assessment, 151–152 monopolizer, in groups, 432–434, 439, 459–462 motivating skills, 273; coping questions, 272; exception questions, 272; for reassurance and hope, 272–273; strengths identification, 272; in TI practice, 286–287 motivation, community mobilization and, 559, 567 MRI. See Mental Research Institute MSW. See Master of Social Work multidimensionality, 128 Muslim (Islam) worldview: intersectionality of HIV, 128; militant and radical Islam, 120; religious belief system of, 119; Shiite and Sunni, 119; values of, 119–120 mutual aid, 566; bereavement group and, 289–292; in groups, 193–194, 251, 419; mental illness and, 364 Mutual Aid Model, 22 mutual aid tradition, 22; as protective factor, 74 mutuality about focus and role expectations: in Critical Incident Analysis, 664–665, 673; in Record of Service sample, 658 NA. See Narcotics Anonymous NAACP. See National Association for the Advancement of Colored People NAC. See National Alliance for Children

INDEX

|

742

NACW. See National Association of Colored Women NAMA. See National Alliance of Methadone Advocates Narcotics Anonymous (NA), 44, 282, 556 NASW. See National Association of Social Workers National Alliance for Children (NAC), 630 National Alliance of Methadone Advocates (NAMA), 558 National Association for the Advancement of Colored People (NAACP), 12, 13 National Association of Colored Women (NACW), 12, 13 National Association of Social Workers (NASW), 21; Code of Ethics of, 87–88, 94, 101, 229, 547, 609; Legal Defense Fund of, 609; PACE of, 640 National Bureau of Economic Research, 40 National Child Traumatic Stress Network (NCTSN), on research studies, 49 National Conference of Charities and Corrections (NCCC), 6, 17 National Conference on Social Welfare (NCSW), 6 national curriculum study, by CSWE, 28 National Urban League (NUL), 12, 14 Native Americans, 14–15; education reformers and, 15; mental health worldview of, 120; trauma history of, 120; worldview of, 120 natural disasters, 78; Hurricane Katrina, 70, 71; Hurricane Sandy, 76–77 natural networks, for recruitment, 557–558 NCCC. See National Conference of Charities and Corrections NCSW. See National Conference on Social Welfare NCTSN. See National Child Traumatic Stress Network need-meeting policies, 615 negation, group example of, 521–522

negative cycles, 262 negative feedback practices, 2 negative feelings separation phase, 516, 522–525, 527 negotiating, as consensus or conflict strategies, 571 Negro Family in the United States, The (Frazier), 14 Negro in the United States, The (Frazier), 14 neighborhoods: discrimination as stressor in, 546; methods and skills for, 103; NASW Code of Ethics on empowerment in, 547; public substance abuse treatment program in, 553–554; settlement house emphasis on, 25; stressors for, 546–547; terminology of, 546; violence as stressor in, 546–547 neonatal intensive care unit (NICU), 203, 209, 281 networking, in social work lobbying, 618, 622–625, 631, 638–639 networks interdependence, in deep ecology, 2, 80 New Deal, 30 New York School of Social Work, 11 New York University School of Social Work Information for Practice, 49 niche, 2, 55, 61, 67, 100 NICU. See neonatal intensive care unit 9/11 terrorist attack, 39, 42 Noah’s Ark principle, for group composition, 201 nondiscrimination, 87 nonlocale communities, 546 nonverbal communication, 184; anticipatory empathy and client, 188–189; clients, 145, 146, 188–189, 230; cultural competence and, 147; information collection and, 229–230; physical touch and, 186–188; social workers, 145, 146, 185–188, 229–230 normative patterns, 654–655

743

nuclear family, 368 NUL. See National Urban League Obamacare. See Affordable Care Act ongoing groups, 203–204 ongoing phase, of life-modeled practice, 3, 173–174; social work methods in, 110–112 online clearinghouses, on research, 48–49 online counseling, 44; boundaries and dual relationships in, 89–90; ethical guidelines for, 89–90; informed consent in, 89; privacy and confidentiality in, 89; professional responsibilities in, 90; Reamer on, 89–90; on records and documentation, 90 online sites, for AA and NA, 44 open-ended groups, 203–204 open-ended questions, 229 opioid abuse, 31, 633 opportunity-enhancing policies, 615 oppositional defiant disorder, 220–222 oppression, 55; Latino worldview and, 119; mental illness and, 125–126; of women, 2, 81 organic depression, 145 organizational analysis: force-field analysis, 3, 591, 680–681; initial skills for, 594 organizational change: complexity and formalization impact, 592; entry phase for, 594–596, 600; environmental forces for, 591, 604; interpersonal forces for, 592–593, 604; organizational forces for, 591, 604; preparation phase for, 587–594; social worker influence for, 593 organizational climate: discomfort creation and management, 596, 598–600; personal positioning in, 596; structural positioning in, 596–597 organizational factors, for endings helping process, 510–512, 515

|

INDEX

organizational forces, for organizational change, 591, 604 organizational policies, methods and skills for, 103 organizational self-awareness, of social workers, 593 organizational stressors practice illustrations: adolescent and teacher mediation example, 350–351; animal support example, 362–363; on client assertiveness and empowerment, 343–344; client built and natural environments, 358; client community outings and, 361–362; client competence example, 342–344; community outings example, 361–362; elderly clients advocacy example, 344–346; on elderly residents food service, 344–346; foster child placement decision, 353–355; foster children self-advocacy skills, 346–348; homeless client mediation example, 351–353; housing for cognitively impaired client, 358–361; mental illness and mutual aid example, 364; mutual aid and mental illness, 364; rape victim advocacy, 355–358; rape victim empowerment, 348–350; speaking on behalf of foster child example, 353–355 organization of information, as assessment task, 144 organizations, 2, 581; on agency social work purpose, 585; clients spatial needs in, 334–335; engagement in, 601–613, 610; external organizational stressors, 582–583; internal organizational stressors, 583–584; professional role and self-interest in, 584–585; regulatory power over, 632 other-awareness, 392 outcomes, organizational change preparation phase and hoped-for, 588

INDEX

|

744

outpatient substance abuse treatment program, 47 overgeneralizations, 128 Oxley, Lawrence A., 14 PACs. See political action committees paraphrasing, 231–232 parent-child family system, 371, 375; practice illustration on, 397–401 parenthood transitions, LGBTQ challenges of, 71–72 parenting, LGBTQ stigma for, 72 partner family system, 371–372 partnership, client-social worker relationship of, 132, 154, 229 Patriot Act. See Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism patterns: in bereavement group assessment, 653–655; exploring and clarifying skills for exploration of, 267–268; in family assessment, 648–649; maladaptive communication and relationship, 84; normative and sanctioning, 654–655; transactions perspective on maladaptive, 494. See also client-social worker relationships, maladaptive patterns in PCAA. See Prevent Child Abuse America peer alliances group example, 437–439 people of color: Chinese Americans, 16; health disparities for, 34–36; incarceration of, 31, 33; institutional racism of, 32–33; Japanese Americans, 16–17; Mexican Americans, 15; Native Americans, 14–15; privilege and, 133; social work historical development and, 11–17. See also African Americans perceived level of fit, 58 perceptions and behaviors legitimization, 392

Perlman, Helen Harris, 18 permeable family boundaries, 370 personal positioning, in organizational climate, 596 Personal Responsibility and Work Opportunity Reconciliation Act (PPWORA) (1996), 41; charitable choice clause in, 42 person:environment: adaptive exchanges in, 58, 60; reciprocity of, 1–2, 56–58; resilience in transactions of, 2, 73–74; transactions, 73 persuasion: issue definition in, 604; monitoring skills and, 605–606; opposition anticipation and, 605; in organization engagement, 604–607, 610; solutions, presentation for, 606; supports for, 604–605 persuasive and assertive skills, 329–331, 333 physical disabilities: discrimination of, 126; intersectionality of, 129; stigma of, 125, 126; stroke example, 148–152 physical environments, 3, 335; in Critical Incident Analysis, 665–666; deep ecology and, 80, 81; groups and, 195; in individual assessment, 646–647; psychiatric facility example of, 318; SSC organization and elderly clients, 317–318; toxic contamination, 319 physical functioning, stress impact on, 68 physical touch, 186; CSA example, 187; grief example, 187; interns example, 188; LGBTQ example, 188; misinterpretation of, 239 physiological stress, 2; from poverty, 68–69 planned short-term services, 215 plans: in family assessment, 650; in individual assessment, 647 play, for children engagement, 106 police reform, 579

745

policy practice, 28, 614; on asset accumulation policies, 615; on economic development policies, 615; Jansson on, 29; legislative advocacy and, 29; on need-meeting and equity-enhancing policies, 615; on opportunity-enhancing policies, 615; on public improvement policies, 615; on public safety policies, 615; on regulations, 615; on right-conferring policies, 615; on social services, 615 policy specialists, 29 political action committees (PACs), 61 political advocacy, 2, 615–616, 631 political campaigns work, 640 political context understanding, in CSA legislation illustration, 629 political engagement, social justice through, 641–642 political level, of life-modeled practice, 543–544 political parties, polarization of, 30–31 politics. See electoral politics; legislation Poor Law philosophy, 6 positive feedback processes, 2 posthearing activities, in regulatory process, 635–636, 637 posttraumatic stress disorder (PTSD): example, 560; Hurricane Katrina and, 70; veterans example, 336, 426 post WWII recovery, 25 poverty: children in, 33; as community and neighborhood stressor, 546; Current Population Survey ASEC on, 32; data on, 32; deep, 33; federal government and rate of, 40; health disparities, 34–36; impact of, 32; income inequality, 34; physiological problems from, 68–69; structural family approach to, 24–25; women and, 33 power and powerlessness: abuse or misuse of, 2, 55, 61; adaptedness

|

INDEX

enhancement of, 62; coercive and exploitative, 67; deep poverty and, 62; of microaggressions, 127; organizations and regulatory, 632; social reality of, 129; worldview on, 117. See also empowerment practice analysis, in Critical Incident Analysis, 667–671, 675–676 practice evaluation: assessment link to evaluation outcomes, 162–166; assessment use for evaluation outcomes, 166–169, 169; case study method, 162; cautionary notes on, 171–172; client satisfaction survey, 169; goal attainment and task achievement scaling, 169, 170– 171; goals and objectives establishment, 169, 170–171; group comparison method, 162–163; RAIs, 165, 169, 169–170; single-subject design method, 163–166, 169; time frames in, 171 practice guide, research as, 45–49 practice modality: case example, 212–213; family, 211–212, 214; group, 211, 214; in helping process, 210–213; individual, 210–211; selection of, 214 practice monitoring, 3; Critical Incident Analysis instrument, 161, 162; Record of Service instrument for, 161–162, 657–661 practice outcomes: CSA example, 166–168, 171–172; evaluation of, 3 pragmatism, 9 precontemplation stage of change, 156, 222 pregnancy: adolescent denial of, 451–453; Ethical Principles Screen on adolescent, 92–93; values incongruence in homeless mother, 101–102 prehearing activities, in regulatory process, 635–636, 637 prejudice, 136 premature termination, in endings helping process, 509–510

INDEX

|

746

prenatal exposure to substances, mandatory reporting and, 95–96 preparation, for endings helping process: anticipatory empathy for, 514–515; organizational, temporal, and modality factors for, 510–512, 515; relational factors for, 512–514, 515 preparation, in helping process: anticipatory empathy in, 177–190; families work, 191–193; groups work, 193–210; practice modality, 210–213, 214; temporal arrangement, 213–216 preparation phase, for organizational change, 591, 593–594; adolescent health clinic example, 589; community social services example, 590; on hoped-for outcomes, 588; medical hospitalsurgical floor example, 588; mentally ill clients transitional housing example, 588–589; organizational analysis, 591–592; problem identification and documentation, 587–588; senior center example, 589–590 preparatory phase, of life-modeled practice, 3, 108, 173 pressure maintenance, in social work lobbying, 629–630 Prevent Child Abuse America (PCAA), 630 priest, CSA by, 66 primary appraisal, of life stressors, 73 privacy: Ethical Principles Screen on, 92; NASW Code of Ethics on violation of, 95; in online counseling, 89; sexual abuse, substance abuse mandatory reporting, 586–587; technology and, 44–45 private funding, regulatory context for, 630 private nonprofit sector, social work education and, 27 privilege: client disenfranchisement and, 132; social, 132, 136; social reality of, 129, 131; social workers earned, 132;

understanding and acceptance stages for, 133 privileged communication: AIDS example, 97–98; ethical practice on, 88, 96–98; Jaffee v. Redmond, 96; MacDonald v. Clinger on, 96 problem identification and documentation, in organizational change preparation phase, 583–584 procedural research, in social work lobbying, 618–619, 631, 636, 638 process, community organization method emphasis on, 26 professional decision-making, values incongruence and, 101 professional ethical action, values incongruence and, 101 professional function, in life-modeled practice, 2, 83; advocacy efforts in, 45, 53, 85, 112; case example, 84–86; on community resources mobilization, 85; on environmental pressures, 84; legislation political influence of, 85; life stressors and, 86; on life transitions, 84; on maladaptive communication and relationship patterns, 84 professionalization: casework method, 17–20; community organization method, 25–27; family method, 23–25; group work method, 20–22; social administration method, 27–28; social policy method, 28–29 professional responsibilities, in online counseling, 90 professional role, 151 professional socialization, domestic violence example of, 473–475 professional use of self, in helping process, 242–246; self-disclosure, 241 progressive education movement, 20, 21 Progressive Era: African Americans and, 6; agencies in, 6; industrialization and

747

urbanization in, 5; Poor Law philosophy in, 6; science interest in, 7; Social Darwinism in, 7; social reform in, 8; women in, 8 prostrate cancer, avoidance and taboo concern example, 486–487, 498 protection of life, in Ethical Principles Screen, 91–92 protective factors, 2, 56; communities as, 74, 75; environmental elements as, 74, 75; for families, 74; of groups, families, communities, 74, 75, 149–150; Hurricane Sandy and, 76–77; Hurricane Sandy research on, 76; individual characteristics as, 74, 75; resilience and, 73–74, 75 protest, as consensus or conflict strategies, 574 PRWORA. See Personal Responsibility and Work Opportunity Reconciliation Act psychiatric facility, physical environment example of, 318 psychoanalytic theory, 18 psychological impotence, 58–59, 71, 559, 579 psychosocial functioning, 2 PTSD. See posttraumatic stress disorder public defender office: beginning helping process on silence example, 235–237; social worker in, 51 public funding, 582; regulatory context for, 630 public improvement policies, 615 public safety policies, 615 public social welfare sector: agency-based practice in, 50–51; policies of, 27–28 public substance abuse treatment programs, 553–554 Public Welfare Administration (Breckinridge), 28 puzzlement, exploring and clarifying skills for sharing of, 265

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INDEX

quality of life, Ethical Principles Screen on, 92 questions: closed-ended, 230–231; coping, 154–155, 272; miracle, 156, 158, 167; open-ended, 229; scaling, 165, 167; solution-focused, 153, 156, 158, 167, 272; solutions-focused, on exceptions, 153, 272; structuring, 231; why, for adult survivors of sexual abuse, 232 race: self-awareness on, 103, 130; as social construct, 129; social reality of, 117– 120, 129, 131. See also people of color racism, 12; of Chinese Americans, 16; of Japanese Americans, 17; of Mexican Americans, 15 radical approaches, to community practice, 547 RAI. See rapid assessment instrument Rape, Abuse, and Incest Information Network (RAINN), 630 rape crisis, 78, 267–268; center for, 50; trauma example, 303–308; victim advocacy, 355–358; victim empowerment, 348–350 rapid assessment instrument (RAI), 165, 169; in CSA single-subject design, 167–168, 170, 172 rat infestation: locality development approach to, 548, 549–550; multistrategies approach to, 549–550; social action for, 549, 550; social planning for, 549 RCRG. See Rural Community Resources Group Reamer, Frederic: on duty to warn, 94; on ethical challenges, 95; on online counseling ethics, 89–90 reassurance and hope, motivating skills for, 272–273 reciprocal relationships, 56

INDEX

|

748

reciprocity: case example, 57–58; of person:environment, 1–2, 56–58; of relationships and transactions, 56–58 recontracting, group practice illustrations on, 449–451 Record of Service instrument, 161– 162; brief introduction in, 657; consecutive transactions, 658–661; on environmental strengths and limitations, 658; helping steps, 661; life stressor identification, 658; mutuality about focus and role expectations, 658; theory application and research findings, 661 records and documentation, in online counseling, 90 recreational movement, 20 recruitment: diverse perspectives for, 558; natural networks for, 557–558; representativeness for, 557; special individual attributes in, 557 redirection, 232–233 reframing, 392–393 refugees, 37 regulations: analysis of, 634, 637; policy practice on, 615 regulatory context: federal, state, local standards for, 630, 632; Federal Register and, 630; for marijuana legalization, 632–633; over organizations, 632; public and private funded programs in, 630; for SNAP, TANF, and Medicaid, 632 regulatory process: hearings organization, 634–635, 637; IEP practice example, 636–640; influence on, 634–636, 637; prehearing and posthearing activities, 635–636, 637; regulations analysis, 634, 637; regulatory context, 630–634; social worker intervention challenges, 633 relapse stage of change, 156 relational factors, for endings helping process, 512–514, 515

relationships: maladaptive communication and patterns in, 84; reciprocal and unidirectional, 56. See also client-social worker relationships release separation phase, 516, 528–529, 537 relevant information, depression example, 229–230 reliability, 163 religion: Muslim belief system of, 119; in settlement house and COS movements, 8; social reality of, 117–120 Remedial Model, 21–22 renegotiation, in groups, 198 rephrasing, 151, 231–232 representativeness, for recruitment, 557 repression, 266 research: adversarial growth application of, 76; application, on resilience, 76; on engagement and anticipatory empathy, 183–184; on foster care and attachment, 106–107; on LGBTQ parenthood transition, 71–72; online clearinghouses for, 48–49; as practice guide, 45–49; on practice outcomes evaluation, 3; resources, for social workers, 48–49; SAMHSA studies, 49; settlement house movement social, 9; studies links, 49 research findings: in Critical Incident Analysis, 672, 677; on Hurricane Katrina, 71; in Record of Service sample, 661; on stress and coping, 70–72 research-informed practice, 47–48 reservations, of mandated clients, 218–219 residential treatment facility, 50; adolescent rap group for, 426; termination avoidance example, 513–514 resilience, 56; from groups, 193; in person:environment transactions, 2, 73–74; protective factors and, 73–74, 75; research application, 76; theory, 73; of white male, 129

749

resistance, from mandated clients, 462–464 resources: communities mobilization of, 85; environmental, 2, 69–70, 74, 75; groups community example, 198; social workers research, 48–49 retail reform, 8 reverberation step, in anticipatory empathy, 178 revolution, in technology, 43–45 Reynolds, Bertha, 18; casework method and, 19; on client victimization by injustice, 20 Richmond, Mary, 8, 17, 23 right-conferring policies, 615 rigid family boundaries, 370 rituals, in families, 383, 389 role-play: case example, 323–324; court hearing example, 324–325; guiding skills through, 278; for sexual orientation coming out, 340–342 role-soliloquy, 278 Roosevelt, Teddy, 9 Rural Community Resources Group (RCRG), 551–553 sadness separation phase, 516, 525–527, 527 SAMSHA. See Substance Abuse and Mental Health Services Administration sanctioning patterns, 654–655 Satir, Virginia, 23; on communication, 377–378 scaling question, 165, 167 SCAN. See Suspected Child Abuse and Neglect scanning, 440, 562 scapegoat, in groups, 199, 434–436, 439, 446–449 SCC. See Senior Service Center schizophrenia, 23, 104; assessment example, 326–327; helping process beginnings example, 226–227

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INDEX

school-based prevention program, in CSA legislation illustration, 628 Schwartz, William, 22 science: Progressive Era interest in, 7; of social work, 241 Science Daily, Mental Health Research News from, 49 scientific method, worldview on, 117 secondary appraisal, of life stressors, 73 second-order stressors, 384; case example, 385–386 self-advocacy skills, of foster child, 346–348 self-anchored rating, 164–165 self-awareness, 392; on age, 130; for cultural competence and diversity sensitivity, 130; in cultural identity, 130; of gender, 130; on mental illness, 130–131; on race and ethnicity, 130; of sexual identity, 130; of social workers, 130–136; values incongruence and, 101 self-correcting feedback loops, in deep ecology, 2 self-determination, 19 self-disclosure, 241; adult survivors of sexual abuse example, 245; bereavement counseling example, 243–244; case examples, 242; feelings and, 238; guidelines for, 242–243; here and now, 242; rape example, 244–245; sex example, 245; there and then, 242; transparency in, 245–246 self-efficacy, 193 self-esteem, 193 self-help tradition, of African Americans, 12 self-reflection: adult substance abuse example, 269–271; exploring and clarifying skills for, 270–271; values incongruence and, 101 self-stigma, in sexual identity, 124

INDEX

|

750

Senior Service Center (SSC), elderly clients and physical environment of, 317–318 sensitivity to diversity. See diversity sensitivity separateness and connectedness, in families, 381–382 separation phases, in endings helping process: avoidance, 516–522, 527; negative feelings, 516, 522–525, 527; release, 516, 528–529, 537; sadness, 516, 525–527, 527 services: concrete, 582; emergency, 215; episodic, 215; evaluation, in helping process endings, 537–538; FSB, 42–43; long-term, open-ended, 215; for mandated clients, 217–222, 471–472, 512–513; mental health, 23; offered, in degree of choice, 222–223, 224; planned short-term, 215; sought, in degree of choice, 224; time limited, 215. See also Record of Service instrument session length, temporal arrangement and, 216 settlement house: community organization method and, 25; movement, 7–10; neighborhood emphasis of, 25; social action interest by, 25; social reform interest of, 7–10, 25 settlement laws, 6 sex education group, 292–296 sexism, 121 sexual abuse, 166–167, 171, 249; adult survivors of, 78, 141–142, 153–154, 232, 245, 279; case examples, 63–66; privacy and mandatory reporting of, 586–587; as trauma, 77–78 sexual activity: assisted living example and, 332; self-disclosure example and, 245 sexual functioning, taboo concern example, 486–487, 498 sexual identity, 120–122; adolescence, 435; heteronormative, 123; heterosexism

and, 123, 134–135; homophobia and, 123; internalized homophobia, 124; selfawareness of, 130; self-stigma of, 124 sexual misconduct, by social workers, 98 sexual orientation, 123 shame, 224; CSA and, 64; mental illness and, 125 Shiite Muslim, 119 shock trauma setting, 79 sibling family system, 371, 374 silence, in information collection, 233–235 silent member, in groups, 431–432, 439 single parent family, 361, 368–369 single-subject design method, 163; application of, 164–166; CSA example, 167–168, 171–172; mental health example, 164–166; RAI in, 165; selfanchored rating in, 164–165 sit-ins, as consensus or conflict strategies, 574 situational depression, 145 size, of group, 205–206 skills. See social work methods and skills SNAP. See Supplemental Nutrition Assistance Program social action, 1; community organization method on, 27; in community practice, 548, 551; group focus of, 197, 198; for rat infestation, 549, 550; settlement house interest in, 25 social administration method, 27–28 social and normative structures, in, 665–666 social and technological pollution, 2 Social Casework (Perlman), 18 social change: community organization method on, 26–27; groups for, 196, 197, 198 social construct, of race, 129 Social Darwinism, 7 social development, groups for, 196, 197 Social Diagnosis (Richmond), 17, 23

751

social environments, 3, 56; in Critical Incident Analysis, 665–666; groups and, 195; of individual assessment, 646; social networks, 310–312; social welfare organizations, 312–315 social functioning, stress impact on, 68 social goals model, 21–22 social identity, 3; impact of, 48; multidimensionality of, 128 social impotence, 58–59, 559 social institutions, African Americans mistrust of, 118 social isolation, of elderly client, 338–340 social justice, 3, 81; through political engagement, 641–642 social network, 108; diversity of, 136–137; maps, 3 social planning: community organization method on, 26–27; in community practice, 548, 551; for rat infestation, 549 social policy method, 28–29 social pollution, 2, 55 social privilege, 136; examples of, 133–135; lack of, 132; social worker stages on, 133 social problems: in communities, 69; stress and, 69 social reality, 3; of age, illness, and disability, 124–126; of clients, 115, 116–129; of gender and sexual identity, 120–124, 130, 134; of intersectionality, 128–129; of microaggressions, 126–127; on race, 117–120, 129, 131; of religion, 117–120; of social workers, 130–136 social reform: settlement house interest in, 7–10, 25; wholesale and retail, 8 social scientists, in settlement house movement, 9–10 Social Security Act (1935), 28, 41 social services: community, 590; policy practice on, 615 social sustainability, deep ecology and, 80

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INDEX

social time, in life course, 65, 67 Social Welfare Policy and Policy Practice Group (SWPPG), 29 social work: advocacy efforts in, 53; advocacy in, 53; artistry of, 47, 141, 185, 241; historical development of, 1, 5–53; licensing, 49; managed care and, 52; science of, 241 social work education: administration and supervision curriculum, 28; methodological division in, 30; private nonprofit sector and, 27 social workers: accredited program for, 632; African American, 11, 12–13, 14, 137–139; agency-based practice challenges for, 50; avoidance separation phase and reluctance of, 517–519; clients nonverbal communication observation, 145, 146; on communities and neighborhoods empowerment, 547; community modality of, 545; cultural humility of, 135–136; cultural identity of, 130–136; disenfranchisement from privileged position, 132; earned privilege of, 132; in electoral politics, 640–641; legal mandates realms awareness, 93; on level of fit improvement, 59; maladaptive group processes and, 439–446; medical, 50, 148–152; minimal verbal encouragers, 229; nonverbal communication, 185–188, 229–230; organizational change influence of, 593; organizational self-awareness of, 593; personal lives diversity of, 136–142; personal values of, 100–102; privilege and humility of, 131–136; in public defender office, 51; regulatory process intervention challenges, 633; research resources for, 48–49; self-disclosure, 238, 241–246; sexual misconduct by, 98; social privilege stages of, 133; social reality of, 130–136; technology challenges for, 44. See also client-social worker relationships

INDEX

|

752

social work lobbying: agenda building in, 618; coalition-building, 618, 625, 631, 638–639; information collection in, 618, 627–628, 631; key players influencing, 618, 639; legislators and personnel engagement, 618, 620–622, 628, 631; networking, 618, 622–625, 631, 638– 639; political context understanding and use, 629; pressure maintenance, 629–630; strategies for decision makers persuasion, 620; substantive and procedural research, 618–619, 631, 636, 638; testifying, 618, 626–627, 628–629, 631, 640 social work methods and skills, 3, 261– 287; adversarial skills, 331–333, 333; advocacy skills, 112, 392–395, 396; animals for supportive relationships, 334, 362–363; for client recontracts, 497–498; for client release, 537; between clients and built and natural environments, 333–334; in client-social worker relationships, 493–500; clients spatial needs in environment and organization, 334–335; coordinating skills, 111–112, 321–323, 329; for ecological and transaction perspective of maladaptive patterns, 494; enabling skills, 263, 263, 493; environmental stress and professional methods, 320; exploring and clarifying skills, 110, 263–271, 271, 493; facilitating skills, 111, 280–284, 284, 493; guiding skills, 111, 274–280, 280, 493; influencing skills, 112; innovating skills, 112; interpersonal stress acknowledgement, 494–495; for mandated clients, 222; mediating and collaborating skills, 323–328, 329, 333, 350–351, 493, 566; mobilizing skills, 110–111, 493; motivating skills, 272–273, 273; persuasive and assertive skills, 329–331,

333; social worker and environment, 319–320; for social worker reactions and responses, 496–497; supervision for, 499–500; on transference manifestations, 495–496; transparency, 493. See also internal mediating skills social work services, 222–223; clients seeking of, 224–225; skills for offering, 224 societal context, 1; federal government role, 40–41; FSB role, 42–43; global economy, 37–38; immigration, 36–37, 330, 332; of legislation, 40–42; poverty, 32–36; technological revolution, 43–45; terrorism, 38–40 socioeconomic status: disenfranchisement and, 128 socioemotional consequences, of Hurricane Katrina, 70 solution-focused questions: coconstructing cooperation by, 156; on exceptions, 153, 272; miracle question, 156, 158, 167 solution-focused technique, for mandated clients, 156, 241 special individual attributes, in recruitment, 557 specialist, 1 specific feelings, reaching for, 151, 158 SSI. See Supplemental Security Income stages of change, 559; action in, 156, 158; contemplation, 156, 158; determination, 156, 158; gang violence adolescent case example, 220–222; maintenance, 156; mandated clients and, 220–222; precontemplation, 156, 222; relapse, 156, 158–159 stake development, by community members, 562–563, 567 state standards, for regulations, 630, 632 status and power, worldview on, 117 statutory laws: on duty to warn, 93–94; on legal mandates, 93, 95; on mandatory reporting, 93

753

stereotypes, 128; diversity sensitivity and, 115 stigma: of age, 124; of intellectual disability, 126; of physical disabilities, 125, 126 strategic model of family intervention, 388 strengths identification, 272 stress, 73; behavioral challenges from, 68, 69; brain cancer and, 68; case example, 68–69; cognitive beliefs and, 68; cognitive functioning impacted by, 68; from death, 68; emotional problems from, 68, 69; physical functioning impacted by, 68; physiological problems from, 69; research findings on coping and, 70–72; social functioning impacted by, 68; social problems and, 69 stressors: for communities and neighborhoods, 546–547; external organizational, 582–583; groups for common, 196, 197, 198; internal organizational, 583–584; second-order, 384–386. See also environmental stressors; life stressors stroke case example, 148–152 strong feelings, expression of, 444–445 structural family approach, of Minuchin, 24–25 structural positioning, in organizational climate, 596–597 structure creation, by community members, 563–566, 567 structured group meeting, for domestic violence, 424 structuring questions, 231 subgroups and alliances, 199, 437–439, 439 subjective perspective, 65 substance abuse, 69, 212; adult example of, 269–271; of adult survivors of sexual abuse, 78, 279; avoidance example, 282–284; ethical practice for, 90–91; gender differences in, 122; intervention strategies, 48; mandated client group

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INDEX

for, 252–254; neighborhoods public treatment program for, 553–554; opioid, 31, 633; outpatient treatment program, 47; prenatal exposure and mandatory reporting, 95–96; privacy and mandatory reporting of, 586–587; time-limited groups for elderly clients with, 203. See also alcohol addiction Substance Abuse and Mental Health Services Administration (SAMHSA): on research studies, 49 substantive and procedural research, in social work lobbying, 618–619, 631, 636, 638 subsystems: family, 371–376; support, 393 suggestions and advice: CSA example, 275; grieving loss example, 275; guiding skills for, 275–277; in TI practice, 285 summarizing, diabetes example, 233–234 Sunni Muslim, 119 Supplemental Nutrition Assistance Program (SNAP), 632 Supplemental Security Income (SSI), 41–42 supportive demands, internal mediating skills for, 393 suppressed feelings: of denial, 266; of dissociation, 266; exploring and clarifying skills for, 266–267; foster care example, 266–267; of intellectualization, 266; of repression, 266 surveys, for information collection, 555 Suspected Child Abuse and Neglect (SCAN) team, 551–553 SWPPPG. See Social Welfare Policy and Policy Practice Group systems theory, in mental health services, 24 TANF. See Temporary Assistance to Needy Families Tarasoff v. Regents of the University of California (1976), 94

INDEX

|

754

task accomplishment, groups for, 196, 197 task achievement scaling, 168, 170–171, 172 task-centered strategies, 22 task completion, guiding skills for, 278–279 task-focused groups, 197 Tax Cuts and Jobs Act (TCJA) (2017), 34 teacher, client mediation, practice illustration on, 350–351 technology: client-social worker dual relationships and, 45; data breaches and privacy in, 44–45; global economy impacted by, 38; for grassroots and advocacy efforts, 45; moral and ethical issues for medical, 43; online counseling, 44; online support networks, 44; pollution, 2, 55; revolution in, 43–45; social workers challenges in, 44 teen parents outreach program, diversity sensitivity example of, 137–139 temporal arrangements: in bereavement group assessment, 650–651; considerations for, 215; emergency services, 215; episodic services, 215; group structure and, 202–203; in helping process, 213–216; long-term, open-ended services, 215; personal factors for, 216; planned short-term services, 215; in preparation helping process, 213–216; session length and, 216; third-party payment and, 213–214; time limited services, 215 temporal environments, 2 temporal factors, for endings helping process, 510–512, 515 Temporary Assistance to Needy Families (TANF), 40, 41–42, 551–553, 632 terminal illness. anticipatory empathy example, 180 termination: agency-based practice policy on, 90–91; residential treatment facility

example, 513–514. See endings, in helping process Terrell, Mary Church, 13 terrorism, 38; domestic, 39–40; Islamic State terrorist group rise, 39; 9/11 attacks, 39, 42 testifying: in CSA legislation illustration, 628–629; in social work lobbying, 618, 626–627, 628–629, 631, 640 theory application, in Record of Service sample, 661 therapeutic context, as joining method and skill, 389 there and then self-disclosures, 242 thinking-feeling-doing connection, 262, 267, 287–289 third-party payment, 45–46, 51, 53, 93; DSM V diagnosis and, 52; Health Maintenance Organization Act and, 52; temporal arrangement and, 213–214 thoughts, 262 TI. See trauma-informed time, worldview on, 117 time frames, in practice evaluation, 171 time-limited groups: for elderly substance abuse clients, 203; for teen mothers and NICU, 203 time limited services, 215 top-down approach, for communities, 553 toxic contamination, 319 tracking and monitoring, 388–389 traditions: of cultural identity, 3; in families, 383 transactions: environment, in bereavement group assessment, 655; exchanges and, 60; of families, 57; maladaptive process definition on, 443–444; of members, directing group skills, 440; person:environment resilience in, 2, 73–74; perspective, of maladaptive patterns, 494; reciprocity of

755

relationships and, 56–58; Record of Service instrument consecutive, 658–661 transference, 482–485 transgender, 121; disclosure of immediacy example, 241; IEP for adolescent, 633–634 transitional processes: to LGBTQ parenthood, 71–72; of LGBTQ sexual identity, 123–124; as life stressors, 258–261 transparency, in self-disclosure, 245–246 trauma, 84, 174; CSA and, 77–78; domestic violence examples, 240, 249, 250, 470– 471; groups for, 195; indirect, 491–492, 493; life course and, 77–79; long-term challenges from, 77; Native Americans history of, 120; online resources for, 44; periodic assistance examples, 211; rape crisis example, 303–308; sexual abuse as, 77–78. See also posttraumatic stress disorder trauma-informed (TI) practice: anticipatory empathy and, 190; case examples, 78–79; considerations for, 284–287, 335–337; on family secret, 406–412; feelings management in, 286; flooding in, 250; helping process beginnings in, 248–251; information provision in, 285; maladaptive clientsocial worker relationships and, 491– 492, 493; misinformation correction in, 285; motivating skills in, 286–287; suggestions and advice in, 285 trauma-informed (TI) practice illustrations: life stressor and past trauma, 303–309; life transition stigma and past trauma, 300–303 triangulation, 255; double-bind communication and, 378 truancy: anticipatory empathy example, 181–182, 192–193; group scapegoating

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INDEX

example, 434–436; helping process activity use for, 247 Trump, Donald: anti-immigration executive orders by, 31; anti-Muslim rhetoric of, 37, 39; domestic terrorism and, 39–40; executive power abuses of, 61; federal government role reduction, 32; on immigrants, 37; Obamacare repeal threats by, 31, 35 trust, client-social worker relationship and, 105 truthfulness, Ethical Principles Screen on, 92 Tuskegee Institute, 13 undocumented immigrants, 37 unidirectional relationship, 56 uninsured rate, 35 Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism (USA PATRIOT Act)(2001), 42 universality, in groups, 193 universalizing, of clients feelings, 239–240 urbanization, 5; social problems from, 7 USA PATRIOT Act. See Uniting and Strengthening America by Providing Appropriate Tools Required to Intercept and Obstruct Terrorism U.S. Transgender Survey, 121 validity, 163 values: of African Americans, 117–118; of cultural identity, 3; ethical practice core, 86; of managed care, 52; of Muslims, 119–120 values incongruence, 100; NASW Code of Ethics on, 101; in pregnancy, of homeless mother, 101–102; professional decision-making and, 101; professional ethical action and, 101; self-awareness and, 101; self-reflection and, 101

INDEX

|

756

verbal encouragers, 229 verbal report, of client, 144–145 veterans: homeless, 78, 301–303; PTSD example, 336, 426 vicarious trauma, 491, 493 victim assistance program, 105 victimization: by clients injustice, 20; victim assistance program, 105 Vinter, Robert, 21–22 violations: boundary, 98–100; NASW Code of Ethics on privacy, 95; of social workers sexual misconduct, 98 violence, 31; group for adolescents experience of, 428–429; as neighborhood stressor, 546–547. See also domestic violence; gang violence Visiting Nurse Association (VNA), 551–553 visual assessment, 159; ecomap, 3, 160, 160–161; genogram, 3, 161; graphic representations for, 160 visualizations, guiding skills for, 274–275 VNA. See Visiting Nurse Association Washington, Booker T., 13 Washington, Margaret Murray, 13 Wells, Ida B., 13 Western, European/American-centered worldview, 116–117

whistleblowing, NASW Code of Ethics and, 609 white male, resilience and protective function of, 129 white privilege, 131, 579 wholesale reform, 8 why questions, for adult survivors of sexual abuse, 232 women: ecofeminism, 2, 81; feminist movement, 120; feminist theory, 81, 120–121; feminization of poverty, 33; internalized stress of, 121; intersectionality of African American, 128, 129; Latino labor force exploitation of, 129; oppression of, 2, 81; poverty and, 33; in Progressive Era, 8 Women’s March, 45 Women’s Trade Union League, 9 working agreement, 247 worldview, 101; Africentric, 117–118; Asian, 119; of communication, 117; of competition, 116; of families, 383–386, 389; Latino, 118–119; Muslim, 119–120, 128; of Native Americans, 120; Western, European/American-centered, 116–117 youth diversion program: avoidance example, 282–284; groups example, 201–202