One page summary

Ace your studies with our custom writing services! We've got your back for top grades and timely submissions, so you can say goodbye to the stress. Trust us to get you there!


Order a Similar Paper Order a Different Paper

  Chapter 1 

Question >>> 

Social Resources, Human Needs, and the Field of Social Work.

(Book Provided also can use one source) 

2

3

Introduction to Social Work

Second Edition

4

5

Introduction to Social Work
An Advocacy-Based Profession

Second Edition

Lisa E. Cox
Stockton University

Carolyn J. Tice
University of Maryland

Dennis D. Long
Xavier University

6

FOR INFORMATION:

SAGE Publications, Inc.

2455 Teller Road

Thousand Oaks, California 91320

E-mail: [email protected]

SAGE Publications Ltd.

1 Oliver’s Yard

55 City Road

London EC1Y 1SP

United Kingdom

SAGE Publications India Pvt. Ltd.

B 1/I 1 Mohan Cooperative Industrial Area

Mathura Road, New Delhi 110 044

India

SAGE Publications Asia-Pacific Pte. Ltd.

3 Church Street

#10-04 Samsung Hub

Singapore 049483

Copyright © 2019 by SAGE Publications, Inc.

All rights reserved. No part of this book may be reproduced or utilized in any form or by any means,
electronic or mechanical, including photocopying, recording, or by any information storage and retrieval
system, without permission in writing from the publisher.

Printed in the United States of America

Library of Congress Cataloging-in-Publication Data

Names: Cox, Lisa E., author. | Tice, Carolyn J., author. | Long, Dennis D., author.

Title: Introduction to social work : an advocacy-based profession / Lisa E. Cox, Stockton University, Carolyn J. Tice, University of Maryland,
Dennis D. Long, Xavier University.

Description: Second edition. | Los Angeles : SAGE, [2019] | Includes bibliographical references and index.

Identifiers: LCCN 2017030913 | ISBN 9781506394534 (hardcover : alk. paper)

Subjects: LCSH: Social service.

Classification: LCC HV40 .C69 2019 | DDC 361.3—dc23 LC record available at https://lccn.loc.gov/2017030913

This book is printed on acid-free paper.

Acquisitions Editor: Joshua Perigo

Editorial Assistant: Alexandra Randall

Production Editor: Andrew Olson

Copy Editor: Cate Huisman

Typesetter: C&M Digitals (P) Ltd.

Proofreader: Annette Van Deusen

7

Indexer: Kathy Paparchontis

Cover Designer: Gail Buschman

Marketing Manager: Jennifer Jones

8

Brief Contents

1. Preface
2. Acknowledgments
3. About the Authors
4. Part 1 Understanding Social Work

1. 1. The Social Work Profession
2. 2. The History of Social Work
3. 3. Generalist Social Work Practice
4. 4. Advocacy in Social Work

5. Part 2 Responding to Need
1. 5. Poverty and Inequality
2. 6. Family and Child Welfare
3. 7. Health Care and Health Challenges
4. 8. Physical, Cognitive, and Developmental Challenges
5. 9. Mental Health
6. 10. Substance Use and Addiction
7. 11. Helping Older Adults
8. 12. Criminal Justice

6. Part 3 Working in Changing Contexts
1. 13. Communities at Risk and Housing
2. 14. The Changing Workplace
3. 15. Veterans, Their Families, and Military Social Work
4. 16. Environmentalism
5. 17. International Social Work

7. Epilogue: Social Work and Self-Care
8. Appendix: Code of Ethics of the National Association of Social Workers: Summary of Major Principles
9. Glossary

10. References
11. Index

9

Detailed contents

Preface
Acknowledgments
About the Authors
Part 1 Understanding Social Work

1: The Social Work Profession
Learning Objectives
Mary Considers Social Work
The Professional Social Worker

Social Work’s Unique Purpose and Goals
Social Work and Human Diversity

Diversity and Social Justice
Intersections of Diversity

Theory and Practice
Social Work Values

The NASW Code of Ethics
Professionalism
Advocacy

Social Work Education
Social Work Degrees

Bachelor of Social Work
Master of Social Work
Doctor of Philosophy in Social Work or Doctor of Social Work

Field Education
Certificates and Certifications

Social Work Practice
Social Work Roles and Settings
Levels of Practice
Social Work as a Career Opportunity

Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

2: The History of Social Work
Learning Objectives
Brian Organizes Farmworkers
Social Welfare

10

Social Welfare Policy
Conservative and Liberal Ideologies
Social Control
Social Justice

The Intertwined History of Social Welfare Policy and Social Work
Colonial America: 1607 to 1783
Nineteenth Century America: 1784 to 1890
The Progressive Era: 1890 to 1920
World War I: 1914 to 1918
The Great Depression: 1929 to Early 1940s
Rank and File Movement
World War II: 1939 to 1945
America’s War on Poverty: 1960 to 1967
Reaganomics: 1981 to 1989
Partisan Gridlock

The Limitations of Social Welfare
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

3: Generalist Social Work Practice
Learning Objectives
Layla Intervenes at All Levels to Help People Who Are Homeless
Knowledge Base for Generalist Social Workers
Theoretical Foundations of Generalist Practice

Systems Theory
Ecological Perspective
Empowerment Theory
Strengths Perspective
Evidence-Based Practice

Roles for Generalist Social Workers
Levels of Generalist Practice

Social Work With Individuals (Micro Level)
Social Work With Families and Groups (Mezzo or Meso Level)
Social Work With Organizations, Communities, and Society (Macro Level)

The Change Process
Engagement
Assessment
Planning

11

Implementation
Evaluation

Advocates for Change
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

4: Advocacy in Social Work
Learning Objectives
Nancy Advocates to Professionalize Social Work in Her State
The Need for Professional Advocates

Power and Social Inequality
The Ethics of Advocacy

Client Self-Determination
Self-Interest and Advocacy
Individual Benefit Versus Community Benefit
Pathways to Community Benefit

Human Aspects of Helping
Social Workers and Social Change

Cause and Function
Responses to Hard Times
Cause Advocacy Today

The Cost of Advocacy
A Model for Dynamic Advocacy

The Cycle of Advocacy
The Advocacy Model in Action

Tenets of Advocacy Practice and Policy Model
Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

Part 2 Responding to Need
5: Poverty and Inequality

Learning Objectives

12

Steve Sees the Face of Poverty
Poverty

Measures of Poverty
Poverty and Inequality
The Face of Poverty

Women
People of Color
Children
People Who Are Homeless

Social Service Programs for The Those Who Are Poor
Temporary Assistance for Needy Families
Medicaid
Supplemental Security Income
Healthy Meals for Healthy Americans
Supplemental Nutrition Assistance Program
Earned-Income Tax Credit
Public Housing

Diversity and Poverty
Advocacy on Behalf of the People Living in Poverty

Current Trends in Advocacy With People Who Are Poor
Dynamic Advocacy and Poverty

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

The Cycle of Advocacy
Your Career and Poverty
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

6: Family and Child Welfare
Learning Objectives
Rosa Works to Strengthen Families for the Sake of Children
Today’s Families

Diverse Family Forms
Divorce
Separation
Blended Families

13

Single-Parent Households
Same-Sex Marriage and Parenting
Marriage Equality
Cohabitation

Family Problems
Domestic Violence
Child Maltreatment

Child Welfare Services
History of Child and Family Services
Parental Versus Child Rights
A Global Context for Child Protection
Key Child and Family Services

Social Policy and Legislation Supporting Child and Family Services
Public Attitudes Toward Services for Children and Families
Social Workers’ Attitudes Toward Child and Family Services

Social Work in Schools
Challenges Facing School Social Workers

Violence and Bullying
Economically Disadvantaged and Homeless Students
Students With Physical and Mental Challenges
Teen Pregnancy

Improvements in Education to Help Parents and Children
Diversity and Family and Child Welfare
Advocacy on Behalf of Families and Children

Current Trends in Advocacy for Child and Family Services
Dynamic Advocacy and Family and Child Welfare

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Family and Child Welfare
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

7: Health Care and Health Challenges
Learning Objectives
Gayle Practices Social Work in a Teaching Hospital
Health Challenges and the American Health Care System

14

Threats to Americans’ Health
Chronic Illness
Heart Disease
Stress

Health Disparities and the Uninsured
Health Care Policy in the United States

Health Insurance
Affordable Care Act

Health Care Trends
Integrative Medicine
Slow Medicine
Prevention and Wellness
Recovery, Rehabilitation, and Resilience
Inflammation
Managed Care
Electronic Medical Records

Health Care and Social Work
History of Health Social Work
Social Workers’ Roles in Health Care Practice
Health Care Settings

Emergency Rooms and Trauma and Urgent Care Centers
Hospitals and Acute Care
Veterans Affairs Hospitals
Home Health Care
Long-Term Care
Hospice, End-of-Life, and Palliative Care
Rehabilitation Services
Clinics
Public Health Services

Diversity and Health Care
Advocacy on Behalf of People With Health Care Challenges

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Health Care
Summary
Top 10 Key Concepts
Discussion Questions
Exercises

15

Online Resources
8: Physical, Cognitive, and Developmental Challenges

Learning Objectives
Joe Advocates for People With Intellectual Challenges
Definitions of Physical, Cognitive, and Developmental Challenges
Types of Physical, Cognitive, and Developmental Challenges

Developmental Challenges
Physical or Mobility Challenges
Mental/Cognitive Challenges

Stigma and Discrimination Against People With Physical, Cognitive, and Developmental
Challenges
Social Work With People Living With Physical, Cognitive, and Developmental Challenges

Historical Background of Services for People Living With Physical, Cognitive, or
Developmental Challenges
Deinstitutionalization
Americans With Disabilities Act
Social Work Practice With Physical, Cognitive, and Developmental Challenges

Person-First Language
Services for Persons With Physical, Cognitive, and Developmental Challenges

Diversity and Physical, Cognitive, and Developmental Challenges
Advocacy on Behalf of People With Physical, Cognitive, or Developmental Challenges

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career Working With People Who Have Physical, Cognitive, and Developmental
Challenges
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

9: Mental Health
Learning Objectives
Joyce Seeks Knowledge to Help With Her Broad Caseload at a Mental Health Center
Mental Health and Mental Illness

Definitions of Mental Health Status
Normal Versus Abnormal Mental Health
Mental Health Disorders and the DSM

Evolution of the Mental Health System

16

Institutionalization and Deinstitutionalization
Medicalization of Mental Illness
Social Work Perspectives
Mental Deficits Versus Personal Assets
Mental Health Parity and the Affordable Care Act

Social Work Practice in Mental Health
Social Work Roles in Mental Health Services
Mental Health Literacy
Mental Health Settings
Digital Mental Health Information and Therapy

Diversity and Mental Health
Advocacy on Behalf of People With Mental Health Issues

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Mental Health Social Work
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

10: Substance Use and Addiction
Learning Objectives
Clayton Uses His Addiction Experience in Community Outreach
Substance Use as a Mental Disorder

Causes of Substance Use
Codependency
Addictive Substances and Behaviors

Alcohol
Prescription Drugs
Illegal Drugs and Marijuana
Anabolic Steroids
Tobacco and Nicotine
Food and Caffeine
Gambling
Sex Addiction

Policies Related to Substance Use
Social Work Practice in Substance Use and Addiction

Prevention of Substance Use Disorder

17

Treatments and Interventions for Substance Use and Addiction
Detoxification and Recovery
Motivational Interviewing
Alcoholics and Narcotics Anonymous
Needle-Exchange Programs
Methadone Treatment Programs

Diversity and Substance Use and Treatment
Advocacy and Substance Use Disorder

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Substance Use and Addictions
Certifications in Substance use: cadc and ladc

Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

11: Helping Older Adults
Learning Objectives
Emilee Adores Gerontological Social Work
Aging and Older Adults

Meanings of “Aging” and “Old”
Stages of Older Adulthood
Longevity
An Aging Populace

Gerontological Social Work Practice
Evolution of Gerontological Practice
Social Work Roles in Gerontology and Geriatrics
Resources for Successful Aging

Living Options
Day Programs
Benefit Programs
Culturally Competent Care of Older Adults

Issues of Aging and Old Age
Biological and Physiological Aspects of Aging
Cognitive and Psychological Aspects of Aging

Neurocognitive Disorders (Dementias)
Depression, Mental Health, and Other Emotional Problems

18

Substance Use/Addictions
Sexual Activity
Loneliness
Suicide

Social Aspects of Aging
Ageism
Aging in Place
Caregiving
Long-Term Care
Elder Abuse

Spiritual Aspects of Aging
Benefits of Spirituality and Religion in Old Age
Illness, Death, and Faith

Policies Affecting Older Adults
Diversity and Aging

Age
Class
Ethnicity and Race
Gender
Sexual Orientation
Ability
Intersections of Diversity

Advocacy and Aging
Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Gerontology
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

12: Criminal Justice
Learning Objectives
Michelle Combats Racial and Ethnic Imbalances in the Juvenile Justice System
Central Concepts in Criminal Justice and Crime

Types of Crimes
The Contextual Nature of Crime
The Correctional System

19

Juvenile Justice and Corrections
Conflicting Attitudes About Those Who Commit Crimes

Attitudes Toward Punishment
Attitudes Toward Rehabilitation

Social Workers and the Criminal Justice System
Forensic Social Work
Social Work Values Regarding Criminal Justice
Interactions With the Criminal Justice System

Police
Courts
Attorneys
Corrections Officers

Victim Assistance Programs
Deviant Behavior and Social Status
Mental Health and Criminal Justice
Issues Affecting Children and Youth

Exposure and Desensitization to Violent Behavior
Parental Imprisonment

Diversity and Criminal Justice
Specific Disparities in the Criminal Justice System

Racial
Women

Advocacy and Criminal Justice
Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Criminal Justice
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

Part 3 Working in Changing Contexts
13: Communities at Risk and Housing

Learning Objectives
Tonya Supports Residents of Federally Subsidized Housing
Central Concepts Regarding Communities and Housing

Community Practice
At-Risk Communities

20

Housing
Homeownership
Rental Housing
Subsidized Housing
Shared Housing
Halfway Houses
Shelters
Residential Treatment Centers and Hospitalization

Social Work Practice in Housing and Communities
Clients’ Housing Issues

Foreclosure
Landlords
Eviction
Substandard Housing

Social Work With At-Risk Communities
Segregated Communities
Equal Opportunities for Housing
Transportation and Connectivity
Community Development and Resources

Policy Issues Related to Communities and Housing
Homelessness
Affordable Housing
Community Asset Building
Segregation

Diversity and Housing
Advocacy and Housing

Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Housing Services and Community Practice
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

14: The Changing Workplace
Learning Objectives
Deidre Experiences Firsthand the Realities of the Contemporary Workplace
The History of Work

21

Traditional Societies
Agricultural Era: 1630 to 1760
Industrial Revolution: 1760 to 1840
Urbanization: 1860 to 1950
Information Age: 1960 to Present

Current Social Trends Related to Work
Work-Related Issues

Unemployment
Underemployment
Minimum Wage
Gender Inequality
Harassment
Lack of Union Participation
Occupational Health Hazards

Social Welfare and the Changing Workplace
Social Insurance Programs

Unemployment Insurance
Workers’ Compensation
Social Security

Social Welfare Policies
Affirmative Action
Americans With Disabilities Act

Diversity and the Changing Workplace
Age
Class
Gender
Sexual Orientation
Intersections of Diversity

Advocacy and the Changing Workplace
Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in the World of Work
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

15: Veterans, Their Families, and Military Social Work

22

Learning Objectives
Veteran Javier Experienced Military Life and Now Counsels Families
The Armed Services and Military Culture

What It Means to Be a Soldier
How War Affects Soldiers
How the Military Takes Care of Its Own

Social Work With the Military and Veterans
A History of Military Social Work
Behavioral Health Problems of Service Members and Veterans

Traumatic Brain Injury
Posttraumatic Stress Disorder
Substance Use Disorders
Suicide

Issues Affecting Wounded Military Veterans
Issues Affecting Military Families
Programs and Policies for Military Personnel, Veterans, and Their Families
Social Work Assessment and Intervention Skills

Common Types of Therapy
Multidisciplinary Team Approach

Diversity and Military Social Work
Age
Class
Ethnicity/Race
Gender
Sexual Orientation
Intersections of Diversity

Advocacy for Veterans and Members of the Military
Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Military Social Work
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

16: Environmentalism
Learning Objectives
Betty Confronts a Natural Disaster

23

Environmentalism and Social Work
Social Work Leadership in Environmentalism

Mary Richmond
Jane Addams
National Association of Social Workers
Council on Social Work Education

Ecological Social Welfare and Practice
Sustainability
Ecological Justice
Ecological Ethics

Environmental Issues
Overpopulation
Pollutants
Climate Change
Environmental Disasters

Flooding
Drought
Hurricanes
Famine

Diversity and Environmentalism
Age
Class
Gender
Sexual Orientation
Intersections of Diversity

Advocacy and Environmentalism
Economic and Social Justice
Supportive Environment
Human Needs and Rights
Political Access

Your Career in Environmentalism
Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

17: International Social Work
Learning Objectives
Teresa Applies Her Multicultural Background to Social Work
International Social Work

24

Level of National Development
Social Work Principles for International Practice

Transnational Identities
Cultural Competence
Bilingualism and Multilingualism
Comparative Social Policy
Principles of Ethics
Charity and Empowerment
Social Development

Current Issues Facing International Social Workers
HIV/AIDS
Child Welfare
Poverty
Refugees
Safety and Self-Care

Diversity and International Practice
Age
Class
Ethnicity
Race
Gender
Sexual Orientation
Intersections of Diversity

Advocacy and International Social Work
Economic and Social Justice
Environmental Justice
Human Needs and Rights
Political Access

Your Career in International Social Work
International Job Opportunities
Volunteering, Experiential Learning, and Field Education

Summary
Top 10 Key Concepts
Discussion Questions
Exercises
Online Resources

Epilogue: Social Work and Self-Care
Appendix: Code of Ethics of the National Association of Social Workers: Summary of Major Principles
Glossary
References

25

Index

26

27

Preface

When the idea of writing a book was first proposed, our thoughts turned to those people with whom we
wanted to work over a long period of time. Said another way, we recognized that successful writing
partnerships are built on trust, honesty, and commitment. We feel fortunate that those essential elements
culminated not only in lasting friendships but in dedication to a profession that is very much part of our lives.
The completion of this second edition of our book further confirms the worth of highly valued relationships,
lasting friendships, and collective professional commitment.

28

Our Impetus for Writing This Book

We think the second edition of Introduction to Social Work continues to be a timely new text for adoption in
introductory social work courses. Why? Because our book has been crafted to align with the profession’s
historical roots of advocacy for human rights and social, economic, and environmental justice. We know
through our practice and community involvement with social service agencies that many social workers have
been urging and taking a much more active approach in client and community-based advocacy. Throughout
our book, advocacy is described at a clinical/client level and also at organizational, community, national, and
international levels. We encourage readers to connect the needs of individuals with those of society by linking
direct practice to policy development. Engaging in such analytical thinking integrates micro and macro
practice into a holistic perspective of practice underpinned by human needs and rights.

A unique aspect of Introduction to Social Work continues to be its advocacy framework for understanding the
historical development of social work, important figures influencing social work history, multiple practice
settings, and the types of practice performed. The advocacy practice and policy model comprising four
interlocking components—economic and social justice, supportive environment, human needs and rights, and
political access—provides a lens for viewing social issues of the day. Additionally, the model serves as a vehicle
to place special emphasis on human diversity, cultural competence, and intersections of diversity.

Pertinent information is provided regarding professional use of self and contemporary applications to practice
settings to adapt to a changing digital workplace and world. These applications view social workers as
professional practitioners and client and community advocates, thereby offering a clear alternative to the
perspectives of competing books. Features such as Time to Think boxes, Social Work in Action, Spotlight on
Advocacy, and Current Trends provide examples of social work’s dynamic force and contribution to
confronting complicated life situations on individual, group, local, state, national, and international levels.
Vignettes appear across all chapters and are modeled after real-life situations faced by professional social
workers. Perhaps more important, the book’s features prompt readers to pause in thought and consider their
opinions, perspectives, reactions, and strategies related to events often far from their own reality. Our book
encourages readers to stretch and think beyond, to connect the dots, and to critically analyze issues, beliefs,
concepts, and environments. These aspects of cognitive discourse set our book apart from other introductory
textbooks.

In this second edition of our book, special attention was given to feedback from readers and reviewers of our
first edition. Noteworthy changes contained in our second edition are captured below:

Areas for advocacy in social work shift over time. With the election of President Trump and a
republican Senate and House of Representatives, contemporary topics involving social work advocacy
and political action at the federal level have been added and updated, especially in the area of health care
reform.
Increased attention has been given to ethics and the need to apply ethical considerations in social work
practice.

29

A concerted effort has been made to include additional person-first language throughout the text.
Content involving the intersections of diversity and multicultural practice has been enriched.
Additional attention has been given to substance use and addiction services.

30

Structure of the Book

Introduction to Social Work is organized into three parts. Part I introduces readers to a definition of social work,
reviews the history of the profession, and describes advocacy as a major aspect of social work. In this section of
the book, the advocacy practice and policy model is defined through examples and applications. Throughout
the book, the elements of the model serve as themes for exploring practice and policy content areas and
connecting them to vignettes that highlight critical features of each chapter.

In Part II, the chapters examine how social workers respond to human needs—poverty and inequality, family
and child welfare, health care and health challenges, physical and mental challenges, mental health, substance
use and addiction, helping older adults, and criminal justice. The chapters in this section assess the strengths
of people and communities in support of possible advocacy strategies. At every juncture, social workers are
seen as leaders, experts, cofacilitators, and innovators who understand complexities, value diversity, appreciate
the role of culture, and address ethical dilemmas.

We are pleased to write that Part III of Introduction to Social Work goes beyond the standard text coverage by
including chapters on communities at risk and housing; the changing workplace; veterans, their families, and
military social work; environmentalism; and international social work. Each of these chapters introduces
material especially selected to stimulate intellectual curiosity about current topics of relevance, such as climate
change and posttraumatic stress disorder. Additionally, the role of housing is examined in reference to quality
of life and opportunity, the culture of the military is defined so as to better frame the needs of service
personnel and their families, and environmental issues are described innovatively to encourage social work
professionals to be more involved in all forms of life and service.

Each chapter ends with a list of online resources that correspond to the chapter’s content and offer readers the
option to explore multiple topics in more detail. Discussion questions and key concepts are also provided to
support class discussions and possible in-class and out-of-class assignments. A high-interest end-of-chapter
feature titled “Your Career . . .” introduces possible career paths in social work related to the chapter content,
along with thought-provoking questions and/or applications.

31

Making Course Content Come Alive

Although we now primarily identify as educators, we have been molded by our social work practice
experiences, current service endeavors, and the evolving world around us. No matter our work responsibilities,
the classroom remains our playing field where we hope to convey the important role social workers play in
society and people’s lives. We contend that advocacy is critical to teaching, research, and service.
Consequently, Introduction to Social Work is designed to generate critical thinking and discussion, encourage
interactive learning and reflective thinking, and expand horizons. The text will be in e-book format, and
ancillaries are also available. In other words, we took a multisensory approach to teaching and learning that
extends the walls of the classroom to the community and well beyond.

To facilitate teaching, Introduction to Social Work is closely aligned with the Council on Social Work
Education’s new Educational Policy and Accreditation Standards and incorporates reflective practice,
encouraging students to engage in critical thought and reflection and to contemplate a professional social
work career. As suggested by the butterfly on the cover, life is precious, colorful, fragile, and ever changing.
We hope this book will contribute to each reader’s transformation as a person and aspiring professional.

32

SAGE edge

SAGE edge offers a robust online environment featuring an impressive array of tools and resources for review,
study, and further exploration, keeping both instructors and students on the cutting edge of teaching and
learning. SAGE edge content is open access and available on demand. Learning and teaching has never been
easier!

SAGE edge for Students provides a personalized approach to help students accomplish their coursework goals
in an easy-to-use learning environment. Here is a list of features:

Mobile-friendly eFlashcards strengthen understanding of key terms and concepts.
Mobile-friendly practice quizzes allow for independent assessment by students of their mastery of course
material.
Carefully selected chapter-by-chapter video links and multimedia content enhance classroom-based
explorations of key topics.
Interactive exercises and meaningful web links facilitate student use of Internet resources, further
exploration of topics, and responses to critical thinking questions.
EXCLUSIVE! SAGE edge for Students includes access to full-text SAGE journal articles that have
been carefully selected to support and expand on the concepts presented in each chapter.

SAGE edge for Instructors supports teaching by making it easy to integrate quality content and create a rich
learning environment for students. These features include the following:

Test banks provide a diverse range of prewritten options as well as the opportunity to edit any question
and/or insert personalized questions to effectively assess students’ progress and understanding.
Sample course syllabi for semester and quarter courses provide suggested models for structuring one’s
course.
Editable, chapter-specific PowerPoint slides offer complete flexibility for creating a multimedia
presentation for the course.
EXCLUSIVE! Access is provided to full-text SAGE journal articles have been carefully selected to
support and expand on the concepts presented in each chapter to encourage students to think critically.
Multimedia content includes original SAGE videos that appeal to students with different learning
styles.
Lecture notes summarize key concepts by chapter to ease preparation for lectures and class discussions.

33

Acknowledgments

Despite our being experienced social workers, educators, and writers, publishing an introductory textbook has
been a unique and demanding endeavor! The transition in writing style from journal articles and higher-level
textbooks to an introductory book required patience and assistance from the SAGE team. Kassie Graves,
followed by Nathan Davidson and then Joshua Perigo deserve much credit for their contributions to our
writing and for surrounding us with highly talented and dedicated professionals, beginning with, the series
editor, and later copy editor Becky Smith, Abbie Rickard, Libby Larson, Carrie Montoya, and Mary Ann
Vail. For the second edition, Adeline, Alexandra, Andrew, and copy editor Cate Huisman were supportive.
Each of our SAGE colleagues extended professionalism, tenacity, fortitude, and faith in our abilities. Our
sincere gratitude and appreciation go to everyone at SAGE!

Life passes quickly, and we are ever cognizant of the influence and importance of the positive attitudes and
demeanor of colleagues, family members, and friends who have been in our midst and part of our lives. Many
of our thoughts and ideas were stimulated by people close to us. This was especially true of Joan H. Long,
whose excellence in everyday practice as a social worker often served as an inspiration and valuable point of
reflection. Karyn and Judy were inspiring models, and Joey and Mary were consummate cheerleaders.
Graduate assistant Felicia Mainiero, MSW, enthusiastically shared her love for social work practice and
research as she located research articles and compiled references.

Dennis has appreciated having support from his university and colleagues, who have been understanding,
supportive, and tolerant throughout his writing endeavors. He was encouraged by the words of interest
extended to him by faculty, staff members, and professional friends. He is also grateful for mentorship from
noteworthy role models and guides—Fr. Joseph Bracken S. J., Roger Fortin, Neil Heighberger, Tom
Meenaghan, P. Neal Ritchey, Cynthia Geer, Brenda Levya-Gardner, and Teresa Young. Their modeling of
respect, a strong work ethic, time management, humility, balance in life, and grace represent values that
educators try to “pass forward.”

For all of us, as professors, our students play a primary role in our lives. We learn from and with them, and
our thinking and abilities are influenced and shaped by their mere presence. Professionally, there is little more
rewarding than having former students return to campus, call, or send a message to provide an update and
share their life experiences. Students in introductory classes are especially interesting and formidable. Our
deep gratitude goes to our many students and alumni, who have provided us with inspiration and
encouragement throughout our days in higher education.

Finally, a number of experienced educators and seasoned reviewers provided valuable and detailed feedback for
our book. From the very beginning of the review process, they seemed to recognize and appreciate the
advocacy direction we had taken, and diligently sought ways to enhance and improve our work.

Melissa Bird, Portland State University
Brad Cavanagh, Loras College

34

Mickey Correa, City College of the City of New York (CUNY)
Sarah V. Curtis, University of Tennessee
Liz Fisher, Shippensburg University
Samuel W. Gioia, Portland State University
Dianne Greene-Smith, Grand Valley State
Carol Jabs, Concordia University Chicago
Enos G. Massie, Eastern Michigan University
Kenya McKinley, Mississippi State University
Janella Melius, Winston Salem State University
Diane McDaniel Rhodes, University of Texas at Austin
Joy Shytle, Ohio University – Southern
Halaevalu Vakalahi, Morgan State University
Victoria Verano, Florida State University
Melissa Villareal, Grand Valley State
Shane Whalley, University of Texas at Austin
Delories Williams, University of Southern Mississippi
Javonda Williams, University of Alabama
Sheri Zampelli, Long Beach City College

35

About the Authors

Lisa E. Cox,
PhD, LCSW, MSW, is professor of social work and gerontology and a former social work program
coordinator at Stockton University. Prior to 1999, Dr. Cox held a joint faculty appointment at Virginia
Commonwealth University’s (VCU) School of Medicine (Richmond AIDS Consortium) and School of
Social Work, where she taught MSW students and served as a pioneering AIDS clinical trial social
worker with the National Institute of Allergy and Infectious Disease–funded Terry Beirn Community
Programs for Clinical Research on AIDS. Dr. Cox received BA degrees in history/political science and
Spanish from Bridgewater College, and her MSW and PhD degrees from VCU. Since 2007 she has
served as research chair for The Stockton Center on Successful Aging. Dr. Cox teaches undergraduate-
and graduate-level classes in social work practice, gerontology, HIV/AIDS, research, psychopathology,
and cultural neuroscience, and she has co-led study tours to Costa Rica. She was a 2014 faculty scholar
with the Geriatric Education Center Initiative and is a governor appointee to the New Jersey Board of
Social Work Examiners. As a long-standing member of the National Association of Social Workers
(NASW), Dr. Cox has shared her vast practice experience by holding numerous leadership roles within
NASW: National Advisory Board member to the Spectrum HIV/AIDS Project, chair of the Health
Specialty Practice Section, Standards for Social Work Practice in Health Care Settings Task Force
expert, long-term care liaison to The Joint Commission on Health Care, and unit chairperson. Dr. Cox
has presented her scholarship nationally and internationally. She has authored several book chapters and
numerous journal articles focused on health social work, gerontology, international social work, and
social support. Copies of “Garment Workers of South Jersey: Nine Oral Histories” may be obtained on
Amazon.com (ISBN-13: 978-0-9888731-8-6). For relaxation, Dr. Cox plays the piano and enjoys
watching baseball. E-mail: [email protected].

Carolyn J. Tice,
DSW, ACSW, has been professor and associate dean of the Baccalaureate Social Work Program,
School of Social Work, University of Maryland since July 2002. Her prior appointment was chair of the
Department of Social Work, Ohio University, a position she held for 9 years. At Ohio University, she
was the first recipient of the Presidential Teacher Award for outstanding teaching, advising, and
mentoring. Currently, Dr. Tice teaches a first-year seminar and social welfare policy. She received her
BSW from West Virginia University, her MSW from Temple University, and her DSW from the
University of Pennsylvania, where she worked with Hmong refugees. The coauthor of four books, Dr.
Tice focuses her scholarship primarily on the development of critical thinking skills and social work
practice and policy from a strengths perspective. She was a site visitor for the Council on Social Work
Education and is on the editorial board of the Journal of Teaching in Social Work. She serves as a book
prospectus reviewer for Wadsworth Publishers and John Wiley & Sons, Inc. Dr. Tice was a nominee for
the 2015 McGraw-Hill Excellence in Teaching First-Year Seminars Award. In 2008 she was named a
Fulbright specialist and traveled to Mongolia to assist in the development of social work programs. Her
other international social work experiences include program development in Portugal, Taiwan, Vietnam,

36

China, and Botswana. Dr. Tice is a member of the Council of Social Work Education, the Association

of Baccalaureate Social Work Program Directors, the National Association of Social Workers, and the
Social Welfare Action Alliance. For leisure, Dr. Tice operates Olde Friends, a booth in an antique store
located on the southern New Jersey coastline, where she has a family home. E-mail: [email protected].

Dennis D. Long,
PhD, ACSW, is professor in and associate dean of the College of Professional Sciences, Xavier
University (Cincinnati, Ohio). Dr. Long previously served as professor and chair of the Department of
Social Work at Xavier University, and from 2006 to 2012 was a professor and chair of the Department
of Social Work at the University of North Carolina at Charlotte. He received his BA in sociology and
psychology from Ohio Northern University, his MSW from The Ohio State University, and his PhD in
sociology from the University of Cincinnati. The coauthor of four other books and numerous articles,
Dr. Long has focused his scholarship and teaching in the area of macro social work, with special
interests in community-based and international practice. He serves on the editorial board of the Journal
of Teaching in Social Work and is a long-standing member of the National Association of Social Workers
and Council on Social Work Education. Over the years, Dr. Long has provided leadership on numerous
community and national boards, including the Butler County Mental Health Board, Oesterlen Services
for Youth, Charlotte Family Housing, and the National Board of Examiners in Optometry. E-mail:
[email protected].

37

With gratitude and love to my mother Joyce, mon meilleur ami Jacques, and Joey and Mary Ruth.

   LEC

In honor of my mother, Jeanne C. Tice, and William George “Liam” Tice, my mother’s third great
grandchild.

   CJT

With love to Hunter, Joanna, Griffin, and Kennedy—as you continue to be the sparkle in Papa’s eyes.

   DDL

38

Part 1 Understanding Social Work

Chapter 1: The Social Work Profession
Chapter 2: The History of Social Work
Chapter 3: Generalist Social Work Practice
Chapter 4: Advocacy in Social Work

39

Chapter 1: The Social Work Profession

Source: iStock Photo / Alina555

40

Learning Objectives
After reading this chapter, you should be able to

1. Describe the work, goals, and values of social workers.
2. Explain the importance of diversity and advocacy in social work.
3. Appreciate the dynamic nature and roles of the social work profession.
4. Understand educational and practice options for social workers.
5. Compare a social work career to other human services occupations.

Mary Considers Social Work

While in high school, Mary volunteered at a vibrant day care center and a state-of-the-art long-term care facility. She loved working
with the diverse people in both facilities and realized that she was a good listener, doer, and advocate for them. Mary’s school
counselor told her that she might make use of her newly discovered skills by becoming a social worker, a versatile “helping” career.

Mary has begun surfing the Internet and checking other resources, and has learned that with a bachelor’s degree in social work
(BSW) she could work as a generalist practitioner or apply to an advanced-standing master of social work (MSW) program and
quickly become either an advanced generalist or a specialist. Mary has also explored the online website for the Board of Social Work
regulations in her state. Once she receives her BSW degree, she plans to send the board her transcripts so she may be credentialed.
MSW-prepared social workers can work in a wide range of specialty fields of practice, such as hospice, veterans services, and
behavioral health. They can work in community-based settings; various types of institutions; state, federal, or local agencies;
international disaster relief organizations; or political action campaigns.

Mary feels confident that she would enjoy social work, a field where she could advocate for people and causes, help develop policies,
and provide services and resources to people who really need them. As a student, you may be wondering which career might best suit
your personal values and the life you envision for yourself. Social work is a versatile and worthy profession to consider. Integrity,
decency, honesty, and justice are values held in high regard by social work professionals. If you decide to become a social worker, you
will also join a field that provides considerable career mobility and opportunity.

Social work is a helping profession, similar to counseling, psychology, and other human services. Social work is different, though,
and will likely interest you if you care especially about economic, social, and environmental justice and wish to advocate for
individuals, groups, families, organizations, and communities that face disadvantages. To help these groups, social workers require an
understanding of politics and power, and the ability to assess human needs and the environment.

This chapter introduces the goals, competencies, and responsibilities of the 21st century social worker. It describes social work’s core
values, roles, fields of practice, career paths, and employment opportunities to help you decide if the profession of social work is right
for you.

41

The Professional Social Worker

Social work is categorized as a profession because it requires specialized, formal training and certification.
Some of the other professions include law, medicine, accounting, teaching, and counseling. However, social
work’s unique purpose is to infuse change into the lives of individuals and into the community to reduce or
eradicate the ill effects of personal distress and social inequality (Soydan, 2008).

Professional social workers generally graduate from a department, program, or school of social work with
either a bachelor’s or master’s degree (or perhaps a doctorate) in social work. Although some social work jobs
do not require certification, a professional social worker is generally considered to be someone who has
received a social work degree and become certified or licensed by the state in which he or she practices.

Many social workers have achieved historical prominence, such as social work pioneer Jane Addams (who won
a Nobel Peace Prize in 1931), civil rights activist Dr. Dorothy I. Height, and Frances Perkins (the first
woman to serve as a cabinet member, as secretary of labor in 1933). Social work pioneer Del Anderson
transformed veterans services, Bernice Harper led hospice social work, Joan O. Weiss helped establish the
field of genetic counseling, and Dale Masi developed the employee-assistance field (Clark, 2012).

Social work professor and researcher Dr. Brené Brown has become quite successful as a “public” social worker,
offering the profession’s perspective through books, television interviews, and online talks about shame,
vulnerability, and courage. Others with social work degrees who have brought the profession’s perspective to
diverse careers include actor Samuel L. Jackson, writer Alice Walker, and personal finance guru Suze Orman.
Their liberal arts–based social work education was a liberating experience that has served as the foundation for
their life’s work.

42

Social Work’s Unique Purpose and Goals

Throughout history, what human beings have seemed to need most are resources for survival as well as a sense
that they matter. Beyond feeling secure and accepted for who they are, people also hope to live a meaningful,
healthy, and successful life. These are the central concerns of social workers. Their professional role is to help
people secure the basic human needs, rights, and values: food, water, shelter, and such intangible resources as
emotional, economic, and social support.

The purpose of professional social work has been articulated formally by the National Association of Social
Workers (NASW), the voice for the profession (NASW, 1973, pp. 4–5; 2018):

Social work is the professional activity of helping individuals, groups, or communities enhance or
restore their capacity for social functioning and creating societal conditions favorable to this goal.
Social work practice consists of the professional application of social work values, principles, and
techniques to one or more of the following ends:

Helping people obtain tangible services (e.g., income, housing, food)
Providing counseling and interventions with individuals, families, and groups
Helping communities or groups provide or improve social and health services
Participating in relevant legislative processes

The NASW considers social work an applied science and art that helps people who are struggling to function
better in their world and that effects societal changes to enhance everyone’s well-being.

NASW describes four major goals for social work practitioners. The Council on Social Work Education
(CSWE), the arbiter of social work education, adds another goal that relates to social work education. These
goals are presented in Exhibit 1.1.

The general public often confuses social workers with other human service providers, among them school
counselors, mental health counselors, psychiatrists, psychotherapists, public health workers and
administrators, nurses, chaplains, and police or others involved in criminal justice and corrections. While the
roles and settings for some of these occupations overlap, each has distinctive features, perspectives, methods,
and areas of expertise. (See Exhibit 1.2 for more detail on the similarities and differences between social work
and some of these other occupations.) But social workers incorporate the knowledge and skills of these other
occupations as needed to serve clients and communities. They are not limited to a single perspective or set of
methodologies. Thus, at the undergraduate level social workers are called generalist practitioners.

43

Social Work and Human Diversity

In helping and advocating for people in need, social workers inevitably learn about and interact with people
from a variety of backgrounds. Many social workers would argue that one of the most interesting and
rewarding aspects of their career is the ability to expand their knowledge and appreciation of human diversity.
They have an opportunity to learn about the strengths, needs, uniqueness, values, causes, and traditions
associated with various forms of human difference. Consider how much you like hearing people’s life stories.
When you hear people’s life stories, you get clues as to what they need, value, and dream about.

Social Work in Action

44

Dr. Brené Brown Speaks Out
Dr. Brené Brown has a BSW, MSW, and doctorate in social work and serves as a professor and researcher at the University of
Houston’s Graduate College of Social Work. She is also a storyteller. Dr. Brown has authored a #1 New York Times best seller titled
Daring Greatly: How the Courage to Be Vulnerable Transforms the Way We Live, Love, Parent, and Lead (2012), another NYT best seller
titled The Gifts of Imperfection (2010), and I Thought It Was Just Me (2007). For the past decade she has also delivered national
presentations on the concepts of courage, vulnerability, worthiness, and shame. Her work has been featured on Oprah, PBS, CNN,
and NPR. In 2012, Dr. Brown gave a TEDx talk in Houston, Texas, on the power of vulnerability; more than 12 million people
have watched this talk. (TED stands for Technology, Entertainment, Design; TEDx talks are modeled on TED talks, which feature
engaging presentations by experts on a wide variety of topics, but are organized independently.) She is also the founder of The
Daring Way, a training program for helping professionals who wish to implement her findings on courage, shame, vulnerability, and
worthiness in their own work.

In her YouTube clips on the “Power of Vulnerability” and “Listening to Shame,” Dr. Brown discusses how social workers are called
to “lean into the discomfort” and establish meaningful connections with people.

Brown concludes from her qualitative research that “vulnerability is not weakness”; vulnerability requires “emotional risk, exposure,
uncertainty, and fuels our lives.” Essentially, vulnerability is our most accurate measure of courage: “Innovation, creativity, and
change is the birthplace of vulnerability.”

In her clip about shame, she concludes that, although shame is not guilt, it is highly correlated with such behaviors as addiction,
depression, suicide, and eating disorders.

Shame manifests differently in women and men. For example, women often experience shame due to unobtainable or conflicting
expectations. In comparison, men often experience shame when they think they are being perceived as weak.

Source: ©Flickr.com/Dell, Inc. Available under https://creativecommons.org/licenses/by/2.0/deed.en

Dr. Brown exemplifies how a social work education can propel you into a many-faceted future. She is teaching social work students
and the wider world about social work theory and methods. Dr. Brown’s stories about courage, shame, worthiness, forgiveness, and
vulnerability resonate with many. Now they are also adding richness to a social worker’s tool kit.

1. How do Dr. Brown’s ideas and stories help professional social workers eradicate personal distress and social inequality?
2. Consider how vulnerability makes you feel. What role might empathy play for social workers who counsel people who feel

vulnerable?

Clients and collaborators are often quite different from social workers in some significant ways. A person’s life
experiences and circumstances can influence how other people and situations are perceived. What social
workers believe is true depends on their personal values and belief systems. Like everyone else, they are
influenced by family, spiritual beliefs, culture, norms, race and ethnicity, gender and sexual orientation, as well
as life stage, socioeconomic status, ability, and disability.

However, social workers go to considerable lengths to broaden their perspectives. They increase their self-

45

understanding by reading and taking classes (in the arts and humanities as well as on subjects such as
psychology, sociology, sexuality, biology, neuroscience, and gerontology), learning foreign languages, engaging
in personal therapy, participating in self-reflection, and receiving professional supervision and feedback
(Green, Kiernan-Stern, & Baskind, 2005). Through seeking this type of self-knowledge, trained social
workers are likely to become sensitized to the differences among people. They become better at appreciating
other viewpoints and at developing and evaluating more creative policies and intervention strategies (Karger &
Stoesz, 2014; Stoesz & Karger, 2009).

Exhibit 1.1 Professional Social Workers’ Goals

Source: Adapted from Zastrow (2014, pp. 50–51) from primary sites. Goals 1–4 from NASW (1982, p.
17); Goal 5 from CSWE (2008).

Exhibit 1.2 Comparison of Social Work and Similar Occupations

46

If you are contemplating social work as a career, you must look within and evaluate your readiness to advocate
for the typical social work client, who is vulnerable and possibly affected by social injustice. You will also be
required to respond to human needs very creatively, because resource availability and funding usually fall short
of the need, although they vary across communities, regions, and states.

Time to Think 1.1

How well do you think you know yourself? Do you believe you have empathy for others who do not have your privileges? What
elements of your background might give you empathy for those whose human needs are not being met? Are you aware of how others
perceive you and how you come across to others?

Diversity and Social Justice

As rewarding as the experience of human diversity can be, it can be troubling as well. Those who are different
from the types of people with whom we are most familiar are often stereotyped as being inferior in some way.
That prejudiced attitude may lead to actual discrimination in the way those who are “different” are treated.

47

They may have a deprived and constrained childhood, struggle to meet their needs as they age, and feel a
reduced sense of self-worth. Professional social workers are aware of this discrepancy and work toward
economic and social justice, the fair distribution of rights and resources among all members of society.

The bases for prejudice and discrimination, which are discussed throughout the book, include the following
categories of difference:

Class: An appreciable number of social work clients are marginally employable because of low
educational attainment and spotty work records. As a result, they are often stuck in poverty. The jobs
that are available to them generally pay poorly, and so these clients may still struggle with transportation
issues, affordable day care, mental health issues, physical challenges, and affordable health insurance.
Since the beginning of the profession, social workers have advocated for services and programs for
members of the lower classes who need support for a rewarding family life, stable housing, adequate
nutrition, educational opportunity, and employability. Social workers recognize that use of public
assistance is not simply a matter of personal shortcomings. Large-scale issues within the community or
society as a whole (e.g., a shortage of good jobs, inadequate transportation systems, substandard schools,
minimal child-support enforcement, or lack of quality, affordable day care) also undermine a person’s
efforts to advance in life (Seccombe, 2011, p. 74).
Gender: Although women have made important strides in our society, they still face lingering and highly
ingrained gender stereotypes, which are overgeneralizations about behaviors and characteristics based on
whether a person is masculine/male or feminine/female. Social workers partner with women’s rights
groups, educators, and other helping professionals to advocate for and develop positive and meaningful
services and programs for females, especially in education, employment, reproductive services, child care,
and civil rights.
Race: Race is still an issue in the United States, despite decades of social action and legislative and
judicial remedies. Thus, opportunities to promote diversity and social justice for Americans with
African, Latino, Asian, Pacific Islander, Middle Eastern, or Native American heritage are an important
part of social work practice. Social workers who have gained cultural competence effectively help
Bosnian refugees find employment and enroll in ESL (English as a second language) classes, and
advocate for Latino clients who have a mental illness such as schizophrenia to help them avoid repeated
hospitalizations because of language barriers and cultural misunderstandings. By 2050, the U.S.
population is expected to increase by 50%, and minority groups will make up nearly half that population.
One quarter of Americans will be Latino, and 1 in 10 Americans will be of Asian or Pacific Islander
descent. The African American population is projected to increase from 41.1 million to 65.7 million by
2050, going from 14% of the U.S. population to 15% (“Minorities Expected to Be Majority in 2050,”
2008).
Ethnicity: Many people adhere to at least some of the traditions and beliefs of their ancestors. In a
“nation of immigrants,” many ethnic subcultures can be found. However, ethnocentrism, believing that
one’s own ethnic group and way of life are superior to others, can create intolerance and prejudice. In
contrast, social workers promote respect for and understanding of all ethnic groups and cultures. For
example, social workers frequently support ethnic centers, immigrant enterprises, language diversity, and

48

cultural events that showcase ethnic pride and provide a forum for the public to learn about specific
ethnic values and traditions. And well they should: By 2050, immigration will account for almost two
thirds of the nation’s population growth.
Sexual orientation: In recent years, members of the LGBQT (lesbian, gay, bisexual, questioning, and
transgender) community have become far more visible in the process of winning some degree of social
justice for themselves. They have won the right in most parts of the United States to marry members of
the same sex. It is becoming more acceptable in most quarters for LGBQT persons to be themselves,
although discriminatory behavior and interpersonal slights have not disappeared. Social workers counsel
LGBQT individuals facing prejudice, and convene groups with them to discuss ways to cope with both
subtle and aggressive discrimination. Social workers may also advocate for the LGBQT population on a
community, state, or national level.
Age: Older adults, who are ostensibly covered for many of their basic needs through Medicare and Social
Security, often struggle with fixed incomes, health problems, and loneliness. Services such as home-
delivered meals, transportation, and medical coverage for problems of aging may be underfunded or
unavailable for practical reasons. Being acquainted with older adults and attentive to their specific needs
enables professional social workers to improve older adults’ situation. As the population of older adults
grows in the 21st century—by 2050, the population of older Americans (ages 50+) is expected to more
than double—social workers will find themselves more and more challenged to help ensure “good aging”
(Cire, 2014; Lieberman, 2011, p. 137).

Historically, social workers have advocated for justice and human rights for all people, despite their age,
ability, class, race or ethnicity, religion, or sexual orientation. Social workers must challenge “isms”—such as
ageism, ableism, classism, ethnocentrism, heterosexism, and sexism—as they advocate for vulnerable
individuals and groups. However, because social workers are mere humans, mainstream culture influences
their views of people and issues. Social workers are not immune to discriminatory language or “isms,” so if you
choose social work as your career, you must catch yourself and others when you hear language or see behavior
that is ageist, classist, racist, sexist, or prejudicial or discriminatory in any way.

Intersections of Diversity

Social workers typically encounter multiple forms of diversity in a single individual. For instance, a woman
experiencing a physical or mental challenge may also be old and poor. Holes in medical coverage (gaps in the
combined coverage she receives from private insurance, Medicare, and Medicaid) may leave her without
needed treatment and medications. The ever-changing complexity of medical protocols and health insurance
coverage further complicate matters. In turn, the medical issues are an impediment to older, poorer people’s
ability to make doctors’ appointments, keep themselves and their homes clean and in good repair, and buy
medicine or even healthy food. On a regular basis, social workers find themselves creatively seeking to identify
and fill gaps in services for clients with needs that span categories of difference.

Intersectionality refers to the entirety of a person’s dimensions of difference and social identities. Most
diversity includes a complex range or intersection of issues, not simply one. A person may be a poor, old,

49

white, gay, Jewish man who was born with polio and lives in an urban environment. Or a person may be a
single, middle-aged, Christian woman who emigrated from India and works as a nurse in a rural setting.

Some of those areas of difference may create problems in meeting one’s human needs, but others may create
advantages. For example, a man who is a retired middle manager has undoubtedly enjoyed some of the
privileges of gender and class, but if he is also gay or lives with a disability, he may have faced difficulties in his
life that require access to social services. His multiple social locations have sometimes placed him in the role of
being the oppressed and sometimes the oppressor (Jani, Pierce, Ortiz, & Sowbel, 2011).

As a social worker you must understand the complex interrelationships that exist across all social identities so
you can devise strategies that will make a difference and create social change (Adams & Joshi, 2010; Collins,
2010). Keep in mind that people are more than “labels” or any of their categories of difference.

50

Theory and Practice

You may be starting to realize how complex the practice of social work can be. It requires knowledge of
human development and behavior; of social, economic, and cultural institutions; and of the interaction of all
these factors. The social work profession not only provides this knowledge but also educates its members to be
proactive advocates for client systems. The essential lessons for aspiring social workers involve both theory and
practice skills.

Social workers draw on ideas and theories to guide their assessments and intervention decisions. These
perspectives emphasize the importance of resilience, strengths, solutions, social justice, and safe, sustainable
communities. Professional social workers tend to adopt a primary practice theory that fits their views about
human nature, particularly for the purpose of assessing a client, a situation, and the results of efforts to make
changes. Chapter 3 describes these theoretical foundations in more detail.

In addition, many social workers are committed to evidence-based practice, which is, simply stated, using a
particular intervention for an issue, problem, or disorder based on the results of research. They base their
methods on the results of previous studies, because they need to be accountable to clients and third-party
payers (such as insurance companies). In addition, they want to use best practices as documented in their
profession’s knowledge base. Social workers are obligated to ask themselves, “What evidence do I have that
my proposed idea or intervention will help my client?” Your reasoning skills will be enhanced by taking classes
in research methods, policy, and statistics.

The knowledge base for social work is constantly evolving to match developments in other disciplines.
Contemporary social workers embrace technology and neuroscience (Farmer, 2009). Environmental social
work (Gray, Coates, & Hetherington, 2012) and models for social work in a sustainable world (Mary, 2008)
now provide additional ideas and paradigms for social work professionals.

51

Social Work Values

The mission of the social work profession is rooted in a set of core values that undergird social work’s unique
purpose and perspective (Barker, 2014, p. 190; Reisch, 2002):

Competence: Having the needed abilities and skills to effectively help and work with clients
Dignity and worth of the person: Esteeming and appreciating each individual’s uniqueness and value
Importance of human relationships: Interacting and communicating with clients and collaborators with a
dynamic and reciprocal appreciation of one another’s behaviors, thoughts, and feelings
Integrity: Maintaining trustworthiness and adhering to moral ideals
Service: Providing help, benefits, and resources to people so they can maximize their potential and thrive
Social justice: Granting all citizens the same “rights, protections, opportunities, obligations, and social
benefits,” no matter their backgrounds or memberships in diverse groups (Barker, 2014, pp. 398–399)

The NASW Code of Ethics

Social work values are reflected in the NASW Code of Ethics, which serves as a social and moral compass for
social work professionals. This code has four sections—Preamble, Purpose, Ethical Principles, and Ethical
Standards—which are summarized in Appendix A of this book. The Code of Ethics serves six purposes
(NASW, 2018):

Identifies core social work values
Summarizes broad ethical standards
Identifies professional obligations when conflicts arise
Holds the social work profession accountable
Socializes new practitioners to social work’s mission, values, ethical standards, and principles
Defines unethical conduct

Ethical decision making is a process. Oftentimes, social workers struggle with complex scenarios, and the
guidelines help direct their actions. In addition, although the Code of Ethics cannot guarantee ethical
behaviors, and a violation of standards in this code does not automatically imply violation of the law, these
principles stipulate ideals to which all social workers should aspire. Beyond the NASW, many states have
developed social work licensure and/or ethics boards to promote, monitor, and reinforce ethical social work
practice.

Spotlight On Advocacy

52

53

Use of Self
Once students declare they will major in social work, they can expect to do internships or nonpaid fieldwork. Heath Walters (2017)
introduces readers to the importance of bringing their personality in to their social work practice in his article published in The New
Social Worker (http://www.socialworker.com/feature-articles/field-
placement/An_Introduction_to_Use_of_Self_in_Field_Placement/).The term use of self often confuses beginning students. In a
nutshell, this concept means you are combining knowledge, values, and skills gained in social work education with aspects of your
personality traits, belief systems, life experiences, and cultural heritage. To help you integrate your authentic self into skills you will
need in your social work field placement, and ultimately your social work career, it will be helpful to view yourself from five different
perspectives: use of personality, use of belief system, use of relational dynamic, use of anxiety, and use of self-disclosure (Dewane,
2006; Walters, 2017).

Time to Think 1.2

Are you ethical? How do your ethics stand up against social workers’ professional ethics? In the workplace, what might make it
difficult to adhere to a professional code of ethics? You can retrieve more information about The NASW Code of Ethics at this link:
http://www.naswdc.org/pubs/code/code.asp.

Professionalism

In addition to valuing these ethics, social workers identify as professionals. With that status comes a set of
characteristics that help ensure the highest standards of practice: a culture of professionalism, a professional
authority setting standards, recognition of that authority by the community, a systematic body of theory, and a
code of ethics.

Professional identity is currently a hot topic in the counseling profession. A strong predictor of professional
identity is membership in a professional organization, such as the NASW, and pursuing leadership
opportunities in professional organizations. It takes time for professional identity to develop, and it requires
strong mentors who care about investing their time and energy in teaching, leadership, and advocacy.
Professional identity results from a developmental process that facilitates a growing understanding of self in
one’s selected career. When a social worker is able to articulate her or his role to others, within and outside of
the discipline, the process has begun. Next, developing social workers must learn how to merge the personal
and professional by knowing themselves well. Social workers must be in tune with their own personal beliefs
and understand how their life experiences and gender role expectations have shaped them. As a social worker’s
professional identity develops, every area of her or his life will be reflected on.

Likewise, self-awareness—the ability to clearly understand one’s own strengths, weaknesses, thoughts, and
beliefs—is a process that is worthwhile yet not always easy to achieve. Much of the journey to becoming an
effective social worker involves developing your own self-awareness—with classmates, professors, and clients
who continuously challenge your thinking. Getting in touch with your feelings is extremely important. As you
deepen self-understanding, both professionally and personally, you can develop a greater capacity to attend
objectively to your clients’ needs. Being aware and secure in thoughts and feelings leads to good health,
moments of joy, and contentment, which is something every social worker should be mindful of.

54

Advocacy

A key element of social work values that is stressed in this introduction to the profession is advocacy, simply
defined as activities that secure services for and promote the rights of individuals, groups, organizations, and
communities. Advocacy covers everything from ensuring special educational services for a child with learning
disabilities to presenting facts about poverty and needy Americans before the U.S. Congress. Social workers
intercede in not only cases but causes.

Spotlight On Advocacy

55

Suze Orman and National Social Work Month
March is National Social Work Month, first recognized by the U.S. Congress in 1984. It came about because the NASW had
launched a public image campaign several years earlier to advertise what social workers do. President Ronald Reagan signed the
resolution recognizing the many thousands of social workers who dedicate their lives to helping those in need. The resolution
acknowledged that professional social workers are in the vanguard of the forces working to protect children and the aged, reduce
racism and sexism, and prevent the social and emotional disintegration of individuals and families. Every March the NASW
continues to celebrate the profession and raise awareness about what social workers do.

Suze Orman

Source: ©Albert H. Teich/Shutterstock.com

During the March 2012 celebration, NASW invited financial whiz, best-selling author, and television celebrity Suze Orman to help
celebrate social workers. Ms. Orman had earned a bachelor’s degree in social work from the University of Illinois at Urbana–
Champaign but never formally worked in a social work agency. Although she took flak from a handful of social workers for lacking
actual social work experience, Ms. Orman enthusiastically promoted the profession: “Social workers are vital to the fabric of the
United States of America. . . . Those who enter the social work profession know about the low pay, so they need to ‘stand in their
power.’” In addition, Ms. Orman related how her social work studies helped her understand how people think and feel about money,
and enabled her to talk about money on a personal level: “You have to understand people to understand money.” Decent salaries can
be earned in the social work profession, and so she also offered social workers some financial advice. While not all people who
complete social work education will become “Suze Ormans,” graduates who possess degrees in social work will locate meaningful
work and be able to move from setting to setting quite easily. In some respects social work is a business, and your degree is your
ticket to success.

1. What role can social workers play in helping clients be financially literate and good stewards of their money?
2. What do you think about Ms. Orman’s crediting her social work training for her success?
3. What might agencies do to celebrate National Social Work Month?

One of the key differences between social workers and other service professionals is that social workers are
expected to know and care about clients’ environments. That is what undergirds and gives force to their
advocacy.

On a broad level, clients’ environments include issues of economic, environmental, and social justice. As a
professional matter, then, social workers embrace a political vision based on democratic values. They are also
guided by the NASW Code of Ethics, which is influenced by the beliefs and tenets of the three great
monotheistic religions (Judaism, Christianity, and Islam). Social workers envision solutions and engage in
problem solving designed to protect legal and personal rights and to ensure a dignified existence for everyone.
Social work professionals must also understand social and economic conditions. They must understand how

56

economic downturns, the changing balance between conservatism and liberalism, capitalism, and globalization
affect their clients and their practice.

To become a more effective professional advocate, you should seek to expand your worldview. Social workers
who have studied sociology, economics, political science, public health, and other social sciences can better
help clients navigate social service systems and approach decision makers about changes in social policies.

57

Social Work Education

Nearly every state in the United States requires that social workers have a social work degree from an
accredited school. The CSWE is the professional entity that accredits social work programs by monitoring
social work educators and ensuring high educational standards. CSWE is the authority that officially
articulates the goals, values, and training objectives within the profession and oversees curricula development.
Its mission is to ensure that social workers are trained to work at a professional level in many different
dimensions of practice.

In 2015 CSWE delineated nine social work competencies that students in the discipline must acquire and
demonstrate before they graduate. These competencies reflect common practice behaviors and social work
ethics and are measurable. They are intended to ensure that every social work graduate has “sufficient
knowledge, skills, and values” to practice effectively. These competencies, known as the Educational Policy
and Accreditation Standards (EPAS), are summarized in Exhibit 1.3.

58

Social Work Degrees

Social work education is provided at both undergraduate and graduate levels. The CSWE has accredited
undergraduate departments, programs, and schools in colleges and universities that offer social work training.
If you complete an undergraduate degree in social work, you may proceed to graduate social work programs or
immediately take social work positions in agencies.

Since 1971 the CSWE has authorized “advanced standing” for students who have finished approved
undergraduate social work programs, and some schools of social work have made it possible for such students
to obtain their master’s degrees in less than 2 years, some requiring only 1 year of graduate work. Graduate
training programs for the master’s degree in social work in the United States usually take 2 years and combine
instructional classes with fieldwork practice in agencies.

The social work profession, like the psychology and nursing professions, is legally regulated by state licensing
boards and offers specialized credentials and practice certifications. Unfortunately, in some states, no licensure
certification exists for social workers who hold undergraduate degrees in social work. This means that people
who possess other academic degrees can occupy social work positions and sometimes incorrectly call
themselves “social workers,” thereby confusing the general public. Too often the media blame social work for
an act carried out by someone who never received a social work degree but still works in a human service
agency.

Bachelor of Social Work

The Bachelor of Social Work (BSW) degree readies graduates for generalist social work practice, which will
be described in more detail in Chapter 3. The BSW, or BS in social work, is the entry level for the profession.
The academic credential is precisely defined: a bachelor’s degree from a college or university social work
program or department that is accredited by the CSWE.

Important goals of social work education are not only to cover social welfare content and practice skills but
also to provide a liberal arts education so students can become good citizens. The liberal arts–oriented BSW
curriculum introduces student learners to social welfare history, communication skills, human behavior
theories, and critical thinking about diversity and the human condition. Courses with an emphasis on human
biology, economics, statistics, and political science enhance knowledge about human behavior and social
policy development. Increasingly, BSW students also choose to learn American Sign Language or a foreign
language.

Exhibit 1.3 Nine Major Social Work Competencies From the EPAS

59

Source: CSWE (2016), https://cswe.org/.

Master of Social Work

A Master of Social Work (MSW) degree readies graduates for advanced, specialized professional practice. It
must be obtained from a program or department accredited by the CSWE. The MSW degree is viewed as a
terminal degree, meaning that select social work programs may hire MSW social workers as faculty to teach
clinical courses or as non–tenure-track faculty—especially in fieldwork instructor roles.

The curriculum of master’s degree programs builds on generalist, BSW content. MSW students develop a
concentration in a practice method or social problem area; alternatively, some master’s degrees focus on
advanced generalist practice. Thus, the MSW social worker should be able to engage in generalist social work
practice and also function as a specialist in more complex tasks.

The basic program for the MSW degree includes four core areas:

Human behavior and the social environment
Social work practice
Social policy
Research methods

Decades ago, social work education at the master’s level placed considerable emphasis on specialization in
fields such as psychiatric (mental health) social work, medical (health) social work, and school social work.
Since the 1960s the training has centered on a generalist curriculum. Students complete a 2-year training
program that qualifies them to work in some agencies. Additionally, at some schools, the research methods
course requires students to complete an individual or group thesis, a research project, or multiple research
classes. MSW programs also offer elective courses to provide a well-rounded program for graduate social work
students. Dual-degree programs and certificates are also offered at the master’s level.

Doctor of Philosophy in Social Work or Doctor of Social Work

For most social workers, an MSW degree is sufficient for a rewarding career. Although the number of
doctoral programs has been growing, only a small percentage of NASW members hold one of the two
doctorate degrees:

Doctorate of Philosophy in Social Work (PhD): Readies graduates to teach or conduct research or to
specialize in clinical practice
Doctorate of Social Work (DSW): Prepares graduates for advanced practice and administrative
positions or other leadership in social work

Some MSW degree holders who are satisfied with this terminal degree or are working on their doctorates get
jobs teaching at community colleges or in universities as part-time instructors or sometimes in non–tenure-
track “clinical faculty” positions. Other doctorate-level social workers assume administrative positions at

60

agencies or enter private practice as psychotherapists.

These degrees involve advanced and specialized study, a focus on research, completion of a dissertation, and
continuing education credits—especially in the areas of clinical work, cultural competence, and ethics.

61

Field Education

Whichever level of social work education you pursue, you can anticipate spending time in the “real-world
classroom.” Referred to as social work’s “signature pedagogy,” field education is the part of the social work
curriculum that students most eagerly anticipate. In the field you finally get a chance to apply what you have
learned, under the supervision of a credentialed social worker who is approved by the college or university’s
social work program.

The placement settings for field education range widely. Students might be placed in hospitals, courts,
domestic violence shelters, prisons, schools, mental health facilities, nursing homes, and community planning
sites, or with political candidates or NASW chapter offices. In these placements, students engage in practice,
conscientiously applying theoretical concepts and intervention skills learned in the classroom. When students
have completed field education, they are expected to be able to demonstrate all the competencies required of
the generalist social work accredited curriculum.

Time to Think 1.3

How many hybrid or fully online (distance learning) classes are you currently taking? How many of these are social work courses?
What are the advantages and disadvantages of learning about the profession of social work through an internship experience that is
online rather than in person?

62

Certificates and Certifications

In pursuit of their social work degrees, BSW students may complete minors or certificates that verify
specialized knowledge and skills; for example, certificates in child welfare and gerontology are very popular.
After graduation, social work professionals may also wish to obtain special certificates or certifications. Social
work programs, departments, and schools collaborate with continuing education partners to offer the
following:

Credentials such as licensed social worker (LSW), certified social worker (CSW), member of the
Academy of Certified Social Workers (ACSW), licensed master social worker (LMSW), licensed
independent social worker (LISW), and licensed clinical social worker (LCSW)

Beyond the social work degree and professional license, credentials (professional certifications) are often
voluntarily sought by social workers to demonstrate professional commitment, achievement, and excellence in
social work at the national level. The NASW Credentialing Center supplies information about credentials, as
they vary by state. NASW specialty credentials are open to all qualified applicants. For example, certified
social work case managers may receive this credential with only a BSW degree. The majority of other
professional credentials (e.g., ACSW, LMSW, LCSW, LISW) typically require an MSW degree. The
ACSW credential, established in 1960, is available to members and social work leaders in all practice areas
and is a widely recognized and respected social work credential. If a social worker is 2 or 3 years beyond
receiving her or his MSW degree and has accumulated a significant number of supervision hours and taken a
standardized examination, she or he may qualify for the LCSW credential. LCSWs must have either an
MSW, DSW, or PhD degree. Many LCSWs pursue a clinical or mental health counseling path because they
can bill insurance companies for services—whether in private practice or with an agency (NASW, 2014;
2018).

Special certifications such as a Graduate Certificate in Aging Studies or in Addictions and Substance
Use
Certifications such as in Case Management

In all 50 states, social workers have options for becoming certified or licensed at various levels of social work
practice. In fact, it may be illegal to practice social work without a license, depending on the state and practice
setting. Because licensure requirements are not always sufficiently taught to undergraduate students, those
majoring in social work will want to consult handbooks, state statutes, written resources, and websites
(Boland-Prom, Johnson, & Gunaganti, 2015; Groshong, 2009; Monahan, 2013; NASW Press, 2011;
Whitaker, Weismiller, & Clark, 2006).

Social workers must be cognizant of four distinct sets of requirements and guidelines: constitutional law,
common law, executive orders, and statutory law. And social workers’ decisions should be morally defensible
and aligned with the ethical standards of the social work profession (Reamer, 2005). For example, in New
Jersey, hospital-based and MSW-degreed social worker Jessica may assist inpatient clients with discharge

63

planning, information, and referral; however, without her LCSW credential, Jessica is not legally able to bill
patients additionally for the time she spends assessing and counseling. In Florida, mental health social worker
Ameda finds that the LMSW credential she received in New York will not suffice; by virtue of Florida law,
practicing social workers must possess an LCSW credential and complete and document a specific number of
continuing education credits in HIV and domestic violence before they can practice and bill insurance
companies in the state.

64

Social Work Practice

The social work profession’s dual purpose and responsibility is to influence social and individual change.
Knowledge from a variety of disciplines, absorbed from formal classes and personal learning, helps social
workers assess complex situations and determine effective interventions. Many people benefit from and
appreciate these interventions, and our society is better for them. However, social work professionals often
work with individuals and organizations that are not ready for or capable of change. So social workers also
have to use such practice skills as assessing, strategizing, brokering, collaborating, intervening, linking,
listening, motivating, and responding in their professional lives. In addition, they must be ready to pose
alternative solutions, seek consensus, negotiate, and mediate (Theriot, 2013). It is no wonder that social work
is considered a “doing” profession and that it is taught through experiential approaches such as service
learning, internships, and fieldwork.

The multidimensional approach to social work education gives graduates at all levels the knowledge and skills
they need to work in a variety of settings at various levels of practice. It also helps them prepare for a
professional career that offers much personal satisfaction and a promising future, with many opportunities to
grow and blaze new paths.

Social workers must act ethically and help clients make decisions that are ethical. Author Holly Nelson-
Becker (2018) has developed an “Ethical Decision-Making Framework” to help practicing social workers
think through how to “do ethics” for particular clients (see Exhibit 1.4). The framework considers context or
setting of the dilemma, type of client, values, and risks.

65

Social Work Roles and Settings

Traditionally, social workers have provided charity, created agencies and resources, developed or advocated for
policy changes, and delivered services to people and communities in need. Historically, as Chapter 2 describes,
they have been key to the development of social welfare policies, such as child labor laws, fair pay for
minorities and other oppressed people, and relief for the aging and infirm.

Today, the main purpose of social work remains much the same: to empower people to grow and live healthy,
productive, and meaningful lives. Social workers accomplish this purpose by working directly with people,
organizations, and communities, and by acting to change society. Most people who consider social work as
their career choice do so because they want to help people and make a difference.

But social workers’ activities within their practice are more diverse than ever. They help people increase their
capacities for problem solving and coping. They help people obtain needed resources, facilitate interactions
between people and their environments, and make organizations responsive to people. Social workers are also
professional social activists, working to influence social policies affecting their clients and their communities
(Swank, 2012). Here are some examples of the broad array of practice activities they might undertake:

Exhibit 1.4 Ethical Decision-Making Framework

Source: Nelson-Becker (2018, p. 68).

Teaching people how to bring up and nurture children through training and small-group meetings
Caring for older adults through case management and visits to senior centers and hospice facilities
Privately counseling couples with marriage troubles
Modeling how to preserve constructive, safe, and caring households through in-home visits and courses
for family members
Fighting for policy changes within institutions and local and state governments, and for the rights of
persons who cannot fight for themselves, by organizing and leading meetings or writing letters and
articles
Advocating with the national government for veterans who have put their lives on the line for the sake
of others, by writing position papers, speaking in public forums, and testifying before committees

66

Social workers undertake these activities in a wide variety of settings: medical facilities, government and
nonprofit agencies, corrections facilities, home health and long-term care settings, state and federal
government, schools, community-based mental health agencies, faith-based organizations, the military,
veterans programs, corporations, and private practice. Social workers may also find employment in banks,
theater groups, elder law firms, community gardens, police stations, and international agencies (Gambrill,
1997; Gibelman, 1995; Singer, 2009).

Exhibit 1.5 presents an overview of the primary fields of practice, industries, and employers for social workers.

67

Levels of Practice

No matter the precise setting, social workers also categorize their work on the basis of the level of practice, or
the size of the client system with which they intervene: micro, mezzo/meso, or macro. Exhibit 1.6 delineates
these three levels, with examples of each. The particular issues that enter into practice at each level are
discussed in Chapter 3.

Professional social workers often operate on multiple intervention levels. Certainly, across a career, a
professional social worker is likely to experience all three levels of practice. In addition, rarely does a case
involve only one level at a time. For instance, a woman who has been raped on campus and feels traumatized
may need individual counseling, and the social worker may also set up a meeting with her and her parents to
ensure that they are sensitive to the woman’s concerns; the social worker may also intervene with campus
authorities to alert them to a problem that may affect other female students.

68

Social Work as a Career Opportunity

According to the U.S. Department of Labor’s Bureau of Labor Statistics (Bureau of Labor Statistics [BLS].
2014, “Pay”), the median salary for social workers was $44,200 in 2012. However, in social work the pay varies
depending on where you work. For example, salaries for BSW-degreed social workers may start lower at
nonprofit agencies than at government-funded child welfare agencies. Below, in order of annual median wages
from high to low, are the industries that employ the most social workers:

Exhibit 1.5 Overview of Social Work Employment

Source: Data from Bureau of Labor Statistics (2014, “Work Environment”).

Exhibit 1.6 Levels of Practice

Source: Data from “The 25 Best Master of Social Work Degree Programs” (2012).

1. Federal executive branch
2. General, medical, and surgical hospitals
3. Local government
4. State government
5. Individual and family services

Exhibit 1.7 shows the median salaries by skill or specialty of employees with an MSW degree. Keep in mind,
however, that lower salaries may be offset by more opportunities to learn quickly about community resources,
as is often the case when working for a nonprofit agency.

A 25% growth rate is expected for social work employment, which is faster than the average for all
occupations. This expected job growth is a result of an increased demand for social services and health care.

69

However, job growth will vary by industry. The BLS (2014, “Job Outlook”) predicts a 27% employment
increase for health care social workers, 23% for mental health and substance use social workers, and 15% for
child, family, and school social workers.

MSW-degreed social workers will find good opportunities in coming years in the following specialties: aging,
public welfare, child welfare, justice corrections, school social work, health care, employment/occupational
social work, developmental disabilities, community organization, mental health/clinical social work,
management/administration, international social work, research, politics, policy and planning, adoption and
foster care agencies, private practice, employee assistance programs, advocacy and coalition groups, domestic
violence agencies, drug and alcohol rehabilitation centers, nursing homes/skilled nursing homes, homelessness
and hunger advocacy networks, women’s shelters, long-term care facilities, military counseling offices,
assisted-living facilities, senior centers, and social and human services centers (BLS, 2014, “Work
Environment”).

Exhibit 1.7 MSW prepared social workers may receive higher salaries than social workers who possess
undergraduate degrees in social work.

Source: Created by Felicia Mainiero and adapted from Bureau of Labor Statistics, 2016; Social Work
License Map, 2017.

The social work profession will also offer ample opportunity for creativity and innovative solutions in the
future. Developments in scientific knowledge, technologies, and the political economy will continually shape
our world, as will globalization, the changing natural environment, and the aging population. Social workers’
broad education and versatile skills will help ensure that all of us can keep up.

One appealing aspect of professional social work is that it reflects social and technological trends. Among the
areas that promise to provide interesting challenges and opportunities for social workers in the next few years
are the following:

Exhibit 1.8 Many more females than males serve as work professionals.

70

Sources: Figures created by Felicia Mainiero from data at https://www.bls.gov/oes/current/oes_nat.htm
(Figure 1.7) and at https://socialworklicensemap.com/social-worker-salary/ (Figure 1.8).

Teaching and learning: Outstanding communication skills are more essential than ever. Access to, and
instruction in the use of, digital technologies is essential for social work clients. Streaming videos can
teach client viewers about anger management, substance use interventions, or assistive devices to use at
home. Online webinars can help social work professionals acquire new knowledge about mental health
or health care reform.
Research: Genetic counseling and neuroscience are burgeoning sciences that social workers are
embracing. Cultural neuroscience elucidates how early childhood experiences affect our physical and
mental health across the life span. Research that studies the meaning and nature of work is also vitally
needed to inform social work practice. For example, one social work study comparing younger (ages 19
to 34) and older workers found that each group attached diverse meanings to the concept of “work”
(Singh, 2013). In direct practice, social workers should ask which activities qualify as work and which
sociocultural and situational factors influence the general public’s interpretations of work.
Services: Social work hails from a tradition of charity and service. In the future, social workers will need
to become expert navigators and literate interpreters of services that are becoming digitized and being
offered as part of a virtual marketplace, so they can help clients receive what they need. Just as previous
generations of social workers needed to adopt cultural competency, social workers now and in the future
will need to embrace technical literacy (Belluomini, 2013). In addition, some social work practitioners
are offering e-therapy interventions.
Social work education: Social media and technology are radically changing social work pedagogy. Some
graduate programs are now offered completely online. Social work education has also become part of the

71

global marketplace (Askeland & Payne, 2006; Garrett, 2009). Those who have the resources to produce
and distribute social work literature digitally and through social media are able to disseminate their
theoretical views and skills throughout the world. Social workers may have to adapt by researching and
communicating about more universal topics, or on the learning end of the educational enterprise, taking
into account the different local contexts in which information is produced and the different perspectives
from which it should be read.

Current Trends

72

Lifestyle and Technological Change
Over the past three decades, some significant technological changes have occurred. These include the following (Lindsell-Roberts,
2011, p. ix):

Electric typewriters → High-speed computers
Radio → MP3
Encyclopedias → Wikipedia
Wired → Wireless
Letters → E-mail, instant messaging, and texting
Rotary phones → Smartphones
Kilobytes → Terabytes
Local data storage → Cloud storage

These changes have been occurring simultaneously with a number of significant lifestyle changes:

9 to 5 → 24/7
Jet-setters → Cybersurfers
Office workers → Virtual workers
Single skill set → Lifelong learning
Shopping malls → Amazon.com, Craigslist, and eBay
Brick and mortar → Virtual workplaces
Security → Risk taking
Status quo → Constant change
National → Global
Homogeneous → Heterogeneous
Lifers → Job-hoppers

1. How will ever-changing technology likely influence the development of the social work profession?
2. What social work–related apps or e-therapy resources do you or your professors know about? How helpful are these resources

to social workers or people in need?

Time to Think 1.4

If your friends or parents said to you, “Social work doesn’t pay well. Why don’t you major in nursing, psychology, or criminal
justice?” how would you respond? How will social work prepare you to work with people and social problems differently than other
professions would?

Summary

Social workers are professionals who help individuals, families, groups, agencies and organizations, and communities. They work
with people across the life span and across socioeconomic levels. They usually work with oppressed, vulnerable, and disenfranchised
people. People who are suffering because they are ill, addicted, disabled, homeless, poor, immigrants, or discriminated against might
very well be clients of social workers. On the other hand, social workers may also work with social and political elites, as when they
serve as policy planners and program evaluators—although the plight of those at the fringes of society is always at the core of social
work. Unique among other types of professionals, social workers are champions of economic and social justice.

Social workers can obtain employment in multiple settings, including traditional social service agencies as well as courts and
correctional settings, schools, the military, offices and factories, hospitals, mental health agencies, child and family welfare agencies,
long-term care settings, addiction treatment centers, homeless shelters, nonprofit advocacy programs, local/state/federal government
agencies, and legislative bodies. Social workers are found wherever people need help to alleviate personal or social problems.

73

No matter where social workers are employed, common skills and responsibilities exist across the profession:

Providing services to support change not only in the individual but also in his or her environment
Having a knowledge and understanding of human relationships
Improving the problem-solving, coping, and development capacities of all people
Serving as a broker by connecting individuals with resources
Engaging and communicating with diverse populations and groups of all sizes
Creating and maintaining professional helping relationships
Advocating for individual clients or the community to solve identified problems

Job prospects for graduates with BSW or MSW degrees, who learn these skills through classroom learning and field practice, are
very good for the future.

74

Top 10 Key Concepts

Bachelor of Social Work (BSW)
Council on Social Work Education (CSWE)
field education
intersectionality
level of practice
Master of Social Work (MSW)
National Association of Social Workers (NASW)
profession
social work
social workers

75

Discussion Questions
1. What are the values and beliefs of social workers? How do social workers put their values and beliefs into action?
2. Why is self-understanding so important to becoming a social worker?
3. Imagine that you meet a man who felt neglected as a child because his parents divorced and his father was an abusive alcoholic. As

this man ages, he has choices. At one end of the spectrum, he may continue the cycle of addiction, drink heavily, and also become
abusive. At the other end, he may choose never, ever to drink alcohol and become the most responsible person in all his
relationships, always trying to please others. If you grew up in a family where alcohol was never around or was drunk only in
moderation, how would you relate to and help this man?

4. What characteristics do you possess that make you behave ethically? Think of a time when perhaps you or someone you know did
not act in an ethical manner. What was the rationale for the unethical behavior? Looking back, was that a good rationale? Why or
why not?

5. What are the differences in where a BSW social worker and an MSW social worker might work and in how they might practice?

76

Exercises
1. What is important to you in a career? Interview a social worker, and then interview a sociologist, a psychologist, or another human

service professional. Compare and contrast their roles and responsibilities. Ask about their level of education and how quickly they
got a job working with people upon graduation.

2. How would you respond to people (clients) who are poor, ill, or addicted and oppressed? Find out more about these population
groups: Read articles or stories; watch a movie, Fox News, or C-SPAN; listen to NPR; or interview social workers who work with
addicted, mentally ill, impoverished, and oppressed people. Then record your thoughts and feelings about working with people
who are vulnerable and in need of services. For example, here are some of the questions you might explore in a few relevant
movies:

a. The Help: What was your reaction to the oppression of lower-class African American women?
b. Losing Isaiah: What was your reaction to this transracial adoption?
c. Maria Full of Grace: What do you think about how drug/sex trafficking was portrayed?

3. What workplace features or career goals are most important to you? With which clients might you most like to work?
4. On the BLS website (www.bls.gov/home.htm), find the range of salaries for social workers in your local area or state. Compare

salaries across practice settings, such as aging, child welfare, corrections, health, mental health, and school social work. Then
compare the salaries for entry-level BSWs and advanced-practice MSWs (BSW salaries: http://www1.salary.com/Social-Worker-
BSW-Salary.html).

5. Read one of Dr. Brené Brown’s books (e.g., Rising Strong or Braving the Wilderness) and consider the importance of learning to be
both courageous and vulnerable.

Online Resources

American Academy of Social Work and Social Welfare (aaswsw.org): Gathers ideas relevant to the future of the social work
profession through its new initiative, called Grand Challenges for Social Work
Bureau of Labor Statistics (www.bls.gov/ooh/Community-and-Social-Service/Social-workers.htm#tab-2): Categorizes jobs
in social work by sponsorship (where the salary comes from to operate the agency and pay employees), by the kinds of clients
or populations the social worker deals with, and by the kinds of services rendered
Council on Social Work Education (cswe.org): The sole accrediting agency for social work education in the United States
that advocates for social work research and education
International Federation of Social Workers (www.ifsw.org): Contributes to achieving a socially just world through
professional social work; comprises 90 professional social work organizations that care about setting and reviewing
international standards for social work
NASW chapters (www.naswdc.org/chapters/default.asp): All chapters, listed state by state
NASW Occupational Profile Series (workforce.socialworkers.org/whatsnew.asp#profiles)
National Association of Black Social Workers (nabsw.org): Composed of people from African ancestry and guided by the
Principles of the Nguzo Saba to empower and advocate for people of African ancestry and work to create a world without
racial discrimination and oppression
National Association of Social Workers (www.socialworkers.org): The largest membership organization of professional social
workers in the world
The NASW Code of Ethics may be located at this link: http://www.naswdc.org/pubs/code/code.asp or
http://www.vet.utk.edu/socialwork/pdf/NASWCodeofEthics.pdf
The New Social Worker (www.socialworker.com/career.htm)
Social Workers’ Salary Guide (socialworklicensemap.com/wp-content/uploads/2013/05/The-Social-Workers-Salary-
Guide.jpg)
Suze Orman (www.socialworkersspeak.org/hollywood-connection/money-guru-suze-orman-offers-social-workers-financial-
advice.html): Offers financial advice for social workers
U.S. Center for Faith-Based and Community Initiatives (www.usaid.gov/faith-based-and-community-initiatives)
Self-awareness and professional identity resource: http://www.socialworker.com/feature-articles/field-placement/ An
Introduction to Use of Self in Field Placement/

77

Social work practice setting resource: http://www.socialworklicensure.org/types-of-social-workers/types-of-social-
workers.html#context/api/listings/prefilter

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

78

Chapter 2: The History of Social Work

Source: Library of Congress/Contributor/Getty Images

79

Learning Objectives
After reading this chapter, you should be able to

1. Recognize the forces shaping the American social welfare system and social policy.
2. Identify the historical relevance of major social welfare programs that assist people in need.
3. Explore the lives of social work pioneers.
4. Describe the relationship between social welfare policy and the social work profession.
5. Explain why social welfare policies that address people’s immediate needs are inadequate for promoting social justice.

Brian Organizes Farmworkers

Brian is a community organizer for an organization that supports farmworkers who travel throughout the northwestern United
States. His job involves educating the public about farmworkers’ significant contribution to the American economy and the food
supply. With the farmworkers, Brian focuses primarily on the health needs associated with the pesticides and herbicides found in the
agriculture industry. Since he is bilingual, Brian is often called on by health care providers to translate critical information and
medication dosages to farmworkers and their families. Of late, Brian’s focus has turned to immigration and health care policies.
After researching the nation’s history of farm labor relations, he has helped organize local and regional forums on citizenship and
social welfare benefits and services for farmworkers. Also, Brian has connected farmworkers to other advocacy organizations.

The purpose of this chapter is to convince you that history matters. Specifically, the characters, landmark
decisions, and political environments that encompass the history of social welfare and the development of the
social work profession support a variety of educational purposes that extend beyond the memorization of facts,
dates, and events. You will discover that the profession’s history introduces you not only to social welfare
policy and the practice of social work but also to American politics, diverse and marginalized groups, social
reform movements, leadership strengths and weaknesses, and critical thinking. Perhaps most important, you
will begin to consider how history can guide your development as an advocate for clients and causes, someone
who challenges social injustices.

The historical context of American social welfare policy is a progression of dynamic events, leading
incrementally to an expanded role for government in the human pursuit of the things needed to survive and
even thrive. Examining the history of social work will help you consider two key points: the influence of
political, social, and economic forces on policy development, and the parallel development of social welfare
policy and the social work profession.

Time to Think 2.1

What large-scale events have happened in your life and stand out in your mind? Have any of these events changed the way you think
about places, people, or yourself? When you relive these events, what are your emotions? Why do you think these events affect you
that way?

80

Social Welfare

A critical concept in the history of social work is social welfare, or the array of governmental programs,
services, and institutions designed to maintain the stability and well-being of society (Axinn & Stern, 2005).
Social welfare requires both a common understanding and a formal arrangement between a government and
its people. From this relationship, people have a sense of what they should receive for and contribute to their
well-being. Social welfare reflects the beliefs and values of a nation. It involves the allocation of resources such
as money, personnel, and expertise.

Take a moment to consider the services that citizens of the United States receive from the government. The
list you generate might include education, transportation systems, national defense, and health care. All these
services support people’s well-being, and all could be considered social welfare. Despite this broad perspective,
social welfare issues are hotly debated and central to local, state, and national politics. They are tied up with
social trends, political ideologies, and notions of social control and social justice.

81

Social Welfare Policy

The services and programs made available to certain people for a specified period of time, based on established
criteria, are the product of social welfare policy. Ever-changing social, economic, and political environments
influence policy development and implementation, and so the services associated with policy are constantly
changing. Depending on events, the role of government in improving people’s lives also expands and
contracts. For example, during the 1960s, when the United States experienced considerable public unrest
associated with urban migration, urban violence, persistent poverty, discrimination, and an increasingly
unpopular war, there was a significant expansion of support to poor people and an increase in the civil rights
of a large spectrum of the nation’s population.

American citizens can benefit from social welfare programs that maintain the well-being and stability of our
society.

Source: ©iStockphoto.com/CaptLensCap

Your conclusions on policy questions and social welfare concerns necessitate a vision of society and a sense of
fairness in the redistribution of resources. Your ideas on social welfare policy are likely to include biases and
value conflicts as you move forward in an effort to orchestrate reform or even a restructuring of the American
welfare system.

In the United States, social welfare policies are generally intended to provide a safety net for citizens, services
that protect people from spiraling downward economically or socially and hitting bottom. Eligibility for
“safety net” services depends on meeting specific criteria, or means testing. Means testing is assessing whether
the individual or family possesses the means to do without a particular kind of help. If not, the government
will provide assistance for a designated period of time. Unfortunately, this assistance often produces only a
temporary bounce upward and does little to improve the person’s or family’s overall status in life.

Decisions regarding the direction of social welfare policy in the United States and around the world are always
being made. Your conclusions on any given issue depend on your vision of society and sense of fairness in the
redistribution of resources. How you think about policy issues reflects your political, social, religious, and

82

economic ideologies. It is also likely to reflect your biases and values. Here are some current examples of
policy-related questions for you to consider:

Should we assist persons in poverty through direct cash transfers or through services, through a
combination of the two, or through a new approach that guarantees a universal standard of living?
Which programs should be funded through local revenues, which through states, and which through
federal revenues?
What is the role of the faith-based community in providing social services?
How do social welfare policies in the United States affect or influence the policies of other nations?
How can the social welfare policies of other nations guide the United States?

For social workers, social welfare policy is extremely important. It defines the profession’s clients, specifies
what services will be made available to designated populations, describes how services will be delivered,
outlines the duration of services, and indicates how intervention outcomes will be evaluated and measured.

Current Trends

83

Aid-in-Dying
Oregon, Washington, Montana, Vermont, California, Colorado, and the District of Columbia have legalized aid-in-dying through
legislation, referendums or court cases. If additional states adopted aid-in-dying laws, advocates might actually want to bring a
federal case that could establish constitutional protection in every state.

1. What does aid-in-dying legislation tell you about the citizens of states and possible political and the changing voter trends
across the nation?

2. What are your thoughts on the aid-in-dying legislation?
3. What are the possible unintended consequences?

84

Conservative and Liberal Ideologies

In the United States today, political ideology has a great deal of influence on how people feel about the social
safety net. People with conservative political leanings tend to favor personal responsibility for one’s own well-
being over any form of government support or federally sponsored relief. The underlying premise is that
people in the top echelon of society have worked hard, made smart choices, and earned their lot in life;
similarly, people in distress have caused their own problems and should “pull themselves up by their own
bootstraps.”

Conservative political platforms often take firm stances against taxation (federal income tax, Social Security
taxes, inheritance taxes, state income taxes, and local levies), which is the revenue source for many social
welfare programs. More specifically, many conservative politicians and their constituents are of the opinion
that the nation’s income tax system is counterproductive and undermines a free enterprise, market-oriented
economic system. Usually, conservatives oppose any form of graduated tax rates, which raise the percentage of
taxes paid, or the tax rate, as a person’s income increases. They think this so-called progressive program of
taxation and the government intervention that goes with it place an unfair burden on businesspeople and
entrepreneurs, who create economic expansion, employment opportunities, and the promise of subsequent
wealth.

Source: ©iStockphoto.com/helenecanada

Liberal politicians also support a capitalist, free-market form of government, but they have a different view of
the role of the federal government in social welfare. Liberals typically support a more robust safety net for
poor people, one that attempts to address social issues through moderate or incremental forms of social
intervention and change. Generally, liberals support various types of checks and balances within government,
as well as regulatory and protective policies to help ensure fair competition in the marketplace.

As for taxes, liberals usually want a tax structure that rewards the work of people rather than the profits to be
made through financial investment and manipulation. Liberal leaders also argue that the nation’s tax code
favors the wealthy through unique tax breaks and loopholes benefiting the rich. As a result, middle-class
workers and families are seen as often paying proportionately higher taxes than do those from the upper class.
Liberals generally want to help distribute more wealth and resources to people toward the lower end of the
nation’s socioeconomic structure.

Spotlight On Advocacy

85

86

Barbara Mikulski
Senator Mikulski, who retired in 2016, was the first woman to serve in both the House of Representatives and the Senate. The
longest-serving woman in the history of Congress, the Baltimore native represented Maryland in the House of Representatives for
10 years, starting in 1977. First elected to the Senate in 1986, she began her career as an elected official on the Baltimore City
Council, where she spent five years before coming to Congress. Senator Mikulski is a graduate of the School of Social Work,
University of Maryland, Baltimore, and has had a lifetime committed to services for children and women.

“Barbara Mikulski is among the fiercest advocates [for] women and families that Washington has ever seen,” said Stephanie
Schriock, president of EMILY’s List, which works to get women into elected office and began its efforts by endorsing Mikulski
some 30 years ago. “Barbara Mikulski’s legacy and the tremendous impact of her work will live on in the halls of Congress and across
our country. The EMILY’s List community−now more than three million members strong−thanks her for her leadership and
service” (Wagner & Johnson, 2015).

Source: Courtesy of the U.S. Senate Historical Society

1. What does Senator Mikulski’s career tell you about possible political paths for social workers?
2. Is there a cause you feel strongly about? If so, what time, energy, and other resources are you willing to dedicate to see the

outcome you desire?
3. What other advocates stand out in your mind and why?
4. Read Changing the Face of Power: Women in the U.S. Senate (University of Texas Press, 2005) by Melina Mara and Helen

Thomas. What would you expect to learn from this book and why?

Time to Think 2.2

Read through the definitions of the conservative and liberal political perspectives one more time. Where do you consider your
political leanings to be and why? What were the influences that pointed you in that particular political direction? Are you registered
to vote? If so, do you vote? Consider why you do or do not vote.

87

Social Control

The nation’s social welfare system raises issues of social control, those policies and practices designed to
regulate people and increase conformity and compliance in their behavior. Some people see social control as a
motive embedded in social welfare policy (Trattner, 1999). They point out that many of the social welfare
policies of the 1960s provided people in poverty with government housing, food stamps, and other kinds of
relief in place of training and employment opportunities. Thus, reliance on the government increased while
inequities in education and unemployment went unchecked (Trattner, 1999). Some would argue that these
policies kept people socially controlled and regulated and separated from the rest of society, locked into
unemployment, underemployment, and substandard living conditions (Harrington, 1962).

Social workers are in a position to build on individual and structural strengths while connecting to larger-scale
change. The involvement of social workers in the policy arena helps our society address individual needs and
confront social control—and perhaps shift or redistribute economic and political power so the poor and
vulnerable can better help themselves.

88

Social Justice

Social workers share the common goal of social justice: the endless effort to protect human rights and provide
for everyone’s human needs, such as housing, food, education, and health care, particularly for those in
greatest need. The goal of social justice is what motivates social workers to be advocates. As you will learn,
there are many forms of advocacy; however, here we are concerned with the advocacy that social workers
undertake to challenge the “what is” in society with the “what should be” (Cohen, de la Vega, & Watson,
2001). Although this form of advocacy reflects the political, economic, and social environment in which it is
conducted, some goals are consistent among social advocates across time and circumstance:

Fairness: All citizens have the right to access resources and opportunities.
Equality: All people are entitled to human rights without regard to race, gender, economic, or
educational status, or other distinguishing features.
Freedom: People share the need for independent thought and a sense of security.
Service: The most needy of any society require the most commitment.
Nonviolence: A peaceful approach to collaboration, mediation, or negotiation is more respectful of
others’ rights than is any form of violence.

If you take on a career as a social worker, you will recontextualize many of these goals of social advocacy in
light of your personal and professional experiences.

89

The Intertwined History of Social Welfare Policy and Social Work

As the history of social welfare in the United States has unfolded, so has the history of the profession of social
work. Social and environmental issues confronting various population groups in America (poverty,
unemployment, discrimination, war, oppression, and the like) have helped shape human services and social
programs as well as the nature of social work as a profession.

At times, the United States has developed positive strategies to address specific social problems; consequently,
some groups within the population have made tenuous social and economic gains. However, lasting change
for the larger society has been limited when measured against complex problems of human need and social
justice.

The history of social work and social welfare can be divided into a series of policy eras, designated by
landmark policy decisions and initiatives. Considering history in this way integrates the development of social
work with a series of political issues and environmental factors that have affected what the nation has been
willing and able to do for its citizens’ welfare. The advocacy of social workers has helped ensure a degree of
social justice when the government has addressed social concerns.

90

Colonial America: 1607 to 1783

The early settlers who came to the United States carried with them the traditions, customs, and values of their
countries of origin. Because the majority of the colonists were from England, they conceptualized and sought
to address social problems such as poverty as they would have in England.

In colonial America, welfare assistance took the form of mutual aid; colonists relied on one another in times
of need. It was the community’s responsibility to provide assistance when an individual experienced a hardship
such as a disease or home fire. Relatives and neighbors responded with the necessary assistance until the crisis
situation passed or was somehow resolved. As churches took root in the colonies, they, too, would offer
assistance to needy people. Overall the public attitude toward poor and needy people was respectful and
benevolent, particularly since the harsh living conditions of the colonies placed all the colonists potentially in
harm’s way.

Although the initial systems of colonial assistance were informal, the severe economic and environmental
conditions experienced by the American settlers prompted a more complex system of welfare assistance. The
colonists turned to the principles outlined in the Elizabethan Poor Laws, which were instituted in England in
1601 (Axinn & Stern, 2005). These laws were a response to social and economic forces associated with the
breakdown of England’s feudal system, the reduction of the labor force, and industrialization, which increased
the need for healthy workers. Further, the laws stipulated that taxes would be levied to finance welfare
assistance (Axinn & Stern, 2005).

A concept underpinning the Elizabethan Poor Laws, and the poor laws of colonial America, was the
distinction between the deserving poor and the nondeserving poor (Tice & Perkins, 2002). The deserving
poor included orphan children, elderly individuals, and people with debilitating physical conditions, who
could not provide for themselves through no fault of their own. In contrast, the nondeserving poor were able-
bodied vagrants or drunkards, judged as lazy and unwilling to work for a living. Consequently, work and a
person’s capability or willingness to be self-sustaining through work became an integral part of America’s
social welfare system.

Settlement laws were another feature of the Elizabethan Poor Laws. Designed to control the distribution of
public assistance, the settlement laws were the domain of small units of government and specified a period of
residence for the receipt of assistance. They were implemented throughout the 13 colonies as a standard
requirement for receiving welfare assistance and as a method for localities to monitor the cost of such
assistance.

The colonists adapted other forms of relief from Elizabethan Poor Laws. Outdoor relief provided assistance
to the deserving poor in their own homes and communities; indoor relief provided assistance in institutions
where the nondeserving poor were sent to work (Rothman, 1971). Other approaches to poverty involved
auctioning poor people to wealthy families who were willing to care for them in return for labor and services,
and placing poor and sick individuals under the supervision of couples who were willing to assume

91

responsibility for their care (Axinn & Stern, 2005).

Time to Think 2.3

After reading the definitions of outdoor and indoor relief, please consider examples of those service perspectives today. For example,
what perspective does the meals-on-wheels program represent? What about a mental health or long-term care facility? Are you able
to recognize the influence of the Elizabethan Poor Laws on current social policies and services?

92

Nineteenth Century America: 1784 to 1890

During the 1800s, the U.S. population expanded westward. In the new settlements, mutual aid remained the
main source of help to those in need. An example of this expansion is the orphan trains that ran from about
1853 to the early 1900s, transporting more than 120,000 children, who were often abandoned and alone, from
urban centers to 45 states across the country, as well as to Canada and Mexico. This controversial and unusual
social experiment marked the beginning of the foster care concept in the United States.

However, the 1800s also saw the rise of advocacy on behalf of people who were poor, who had recently
immigrated to the United States, or who were challenged on the basis of physical or mental ability. These
people often faced unjust, inhumane, and harsh treatment. The early advocates were often trying to change
conditions that had been created by local and governmental policies, ordinances, and rules. Dorothea Dix, for
example, was a social activist who lobbied state and federal governments in the mid-1800s to create asylums
for those who were mentally ill, especially those who had no other homes (Ezell, 2001, p. 20).

Advocacy also occurred as social workers became politically active and promoted legislation to protect children
from oppressive labor practices and adolescents from severely punitive juvenile court systems. Activism by
social workers eventually extended to the advancement of the rights of children, workers, women, the elderly,
and racial and sexual minorities.

93

The Progressive Era: 1890 to 1920

By the end of the 1800s, the nation was rapidly urbanizing. There was an enormous influx of immigrants, and
the economy had begun shifting from agriculture and resource based to industry based. These massive social
disruptions led to the economic crisis of the 1890s. There was growing awareness in the United States of the
value of social reform.

Some of the reformers of this era astutely recognized that documentation of human need through written
records was a vital component of advocacy for new policies, practices, and laws. They realized that the general
public and government decision makers could be influenced by numbers, categorizations, and qualitative
accounts and descriptions of social phenomena. Importantly, they laid the foundation in social work practice
for modern data collection systems, comprehensive community needs assessments, and precise descriptions of
human conditions.

At the same time, two new social welfare movements—the Charity Organization Society and the settlement
movement—emerged for dealing with dependency (Reisch, 1998). Each offered a significant contribution to
the development of the social work profession.

The Charity Organization Society (COS) was imported from England to the United States in 1877. The
COS focused on the individual factors related to poverty, such as alcoholism, poor work habits, and
inadequate money management. In general, the COS asked a family in need of relief to fill out an application,
which was investigated to ensure a level of need. Then a friendly visitor, a volunteer committed to helping
COS clients, was assigned to the family and asked to conduct regular home visits. Friendly visitors would
attempt to address individual character flaws and encourage clients to gain independence and live moral lives
(Chamber, 1986). The direct exchange of cash was strictly avoided.

In light of the growing need for a trained staff, charity organizations developed the paid position of “agent” to
visit indigent persons and families and to investigate applications for charity. These agents were the
forerunners of professional social workers (Chamber, 1986). Mary Richmond of the Baltimore and
Philadelphia COS and Edward T. Devine of the New York COS were early leaders in training agents. In
1898, Devine established and directed the New York School of Philanthropy, which eventually became the
Columbia School of Social Work, America’s first school of social work.

The settlement movement turned attention on the environmental factors associated with poverty. In 1889,
Jane Addams, along with Ellen Gates Starr, founded Hull House in a poor Chicago neighborhood where
immigrants lived in overcrowded conditions. Hull House was not the first settlement house in America;
however, it pioneered advocacy roles in social welfare. Its staff collected information about Hull House’s
clients and the residents of the surrounding area and then used this information to influence legislation and
social policy (Dolgoff, Feldstein, & Skolnik, 1993, p. 278). In response to the poverty that surrounded Hull
House, the settlement house also offered day care for children, a club for working women, lectures and
cultural programs, and a meeting place for neighborhood political groups (Axinn & Stern, 2005).

94

Time to Think 2.4

Review the chart entitled Social Work Pioneers (www.naswfoundation.org/pioneers) and consider the common traits of the people
described. How do their lives represent the values and beliefs of social work in action? What does their work tell you about their
political perspectives?

Edward T. Devine, founder of the New York School of Philanthropy.

Source: U.S. national Library of Medicine Digital Collections, ID: 101413608

As a result of these efforts, settlement houses and their staff contributed community organization, social
action, and social group work to the nascent social work profession. However, although Addams and many
others in the settlement movement recognized the existence of class conflict as a reality in the U.S. economic
system, they did not build a mass political organization. Consequently, they did not effectively confront social
class differences on a national level and failed to challenge the overall distribution of the nation’s resources
(Galper, 1975). Instead, settlement house workers supported labor unions, lobbied city officials for sanitation
and housing reforms, and fought discrimination in employment practices.

With the rare exception of Addams and a few other settlement house leaders, those involved in the social
movements of the Progressive Era were not attuned to the needs of racially diverse populations, especially
African Americans (Blau & Abramovitz, 2004). Most reformers took the second-class citizenship of African
Americans for granted and did little to challenge racial barriers and assumptions. It was not until 1909 that
W. E. B. Du Bois, the first African American to earn a PhD from Harvard University, formed the National
Association for the Advancement of Colored People (NAACP). That organization gave African Americans a
movement for fighting segregation in a mobilized and organized fashion (Blau & Abramovitz, 2004).

With social movements of the Progressive Era came the notion of a helping profession oriented toward social
action—in other words, social work. In 1917 Mary Richmond wrote the first social work book, Social
Diagnosis, which introduced a methodology and common body of knowledge for the practice of social work.
Importantly, Richmond embraced assessment and understanding of human relations, social situations and
surroundings, neighborhood conditions, and economic realities. Richmond’s second book, What Is Social Case

95

Work (1922), used six cases from industrialized urban areas to illustrate her definition of social case work.
Thus, the case method of working with individuals and families provided an orderly process of practice with
individuals, with an emphasis on documenting both needs and social conditions to advocate for social change
and reform.

96

World War I: 1914 to 1918

The political environment of the United States in the years before and following World War I supported the
development of social work as a profession but marked a drastic change in its focus. The 1917 Russian
Revolution caused a heightened fear of communism, “radicals” were under attack in the United States, and
social workers retreated from reform to avoid the political arena and persecution. This turn was recognized at
the 1928 Milford Conference, an annual meeting of social work leaders. It was here that Porter Lee, the
director of the New York School of Social Work, reported that social workers had shifted their professional
attention from “cause to function”—from a concern with politics to a concern with the efficient day-to-day
administration of a social welfare bureaucracy (Blau & Abramovitz, 2004, p. 249).

Jane Addams founded Hull House, a settlement house in a poor Chicago neighborhood, in 1889.

Source: Cox/Five College Archives & Manuscript Collections/CreativeCommons.

The turn toward the “function” of social work gave rise to an expansion of practice settings for the profession,
to include private family welfare agencies (as most charity organizations were then called), hospitals, schools,
mental health facilities, guidance centers, and children’s aid societies. The American National Red Cross
employed social workers to provide case work services to families of servicemen and disaster victims in cities,
small towns, and rural areas.

It is important to note that throughout this time period, segregation within the profession continued. The
National Urban League was developed by African Americans in response to their exclusion from much of
mainstream social work services and settings.

The changes in the development of social work were also seen in the number of schools joining the American
Association of Schools of Social Work, which was founded in 1919. The association standardized curricula
and promoted a master’s degree in social work. Both undergraduate and graduate programs became members

97

of the association (Ginsberg, 2001).

W. E. B. Du Bois established the National Association for the Advancement of Colored People (NAACP) in
1909.

Source: Addison N. Scurlock/National Museum of African American History and
Culture/Smithsonian/CreativeCommons.

98

The Great Depression: 1929 to Early 1940s

The stock market crash of 1929, followed by a far-reaching economic depression, brought the United States
to the brink of economic disaster. Social service agencies were unprepared to address the mounting needs of
not only the indigent but also members of the working class. In time, after listening to the narratives of their
clients, social workers began to focus on individual deficits with a growing appreciation for the social and
economic factors associated with dependency and need (Axinn & Stern, 1988). Social workers rekindled the
“cause” orientation that had been abandoned in the 1920s and lobbied the government to provide an adequate
standard of living for all Americans in this time of extraordinary need (Trattner, 1999).

In 1932, the governor of New York, Franklin D. Roosevelt, was elected the nation’s 32nd president. He called
for bold government action and instituted a large federal relief program for the needy. The vast majority of
social workers endorsed President Roosevelt’s New Deal, which included unemployment insurance and a
social security system to deal with the financial insecurity experienced by older persons, dependent children,
and individuals with physical challenges. Harry Hopkins, a social worker, was appointed head of the Federal
Emergency Relief Administration. This was the first federal program to provide relief to the nation’s citizens
on a major scale since the years following the Civil War (Trattner, 1999).

President Franklin D. Roosevelt signed the Social Security Act on August 14, 1935.

Source: Library of Congress, Prints and Photographs Division, LC-USZ62-123278.

The New Deal provided additional employment opportunities for social workers, who were responsible for
state and local public relief. The funds came from a combination of local and federal agencies. Unfortunately,
the relief measures neglected to address racial discrimination; minority groups experienced more economic
hardship than other Americans.

99

Rank and File Movement

In the 1930s, progressive social workers organized the “rank and file movement” and began analyzing and
criticizing aspects of the New Deal. More specifically, as new social service programs appeared, social workers
were hired to administer the programs and serve people in need. The social workers themselves realized they
suffered as workers; they earned very low wages, faced massive case loads, and had living standards that were
barely better than those of their own clients. Consequently, large numbers of progressive social workers joined
the rank and file movement to build labor unions at relief agencies. Additionally, they organized study groups
on capitalism and socialism, established a newspaper called Social Work Today, and formed labor unions at
relief agencies all over the country (see www.rankandfiler.net/about-the-contributors/). Some core leaders of
the movement joined socialist and communist groups, and connected their efforts as social workers to a
broader movement of poor people and workers to fight for a more just economic system.

After World War II, the rank and file movement was disbanded with the nation’s mounting anticommunist
sentiments. In fact, the leaders and spokespeople for the movement were fired from welfare agencies and from
their jobs at social work schools. The labor unions in welfare departments built by the rank and file movement
were outlawed and broken.

The Great Depression and the New Deal had a lasting effect on the nation’s social welfare system—most
notably, enactment of the Social Security Act of 1935. Exhibit 2.1 details the major programs that were part
of the act, which was the result of noisy political compromise. Whatever faults may be found in the
legislation, the Social Security Act widely expanded welfare activities and advanced services and programs for
poor persons. It helped prevent destitution and dependency. The fact that it provided cash benefits to
recipients was a major step toward enhancing human dignity and personal freedom (Axinn & Stern, 1988;
Trattner, 1999).

100

World War II: 1939 to 1945

World War II placed the United States squarely on the global scene and provided near full employment for
most Americans. So during this time, issues of poverty were not on the national agenda or in the forefront of
social work. Still, throughout the war, social workers were involved in services to the armed forces and their
families. In addition, the gains in jobs and income did not apply evenly across races, although Roosevelt did
issue Executive Order 8802 prohibiting discrimination in the defense industries, a significant advancement
toward civil rights in the workplace (Skocpol, 1995; Trattner, 1999).

World War II, and the prosperity that followed victory, changed the nation’s political climate. But the Great
Depression and the New Deal had lasting effects on the social work profession. There were new jobs for social
workers, a deeper understanding of human needs in urban and rural areas, and a renewed interest in reform
efforts. Private and public welfare agencies acknowledged the social work profession as both a “cause” and a
“function” within various fields of practice. The National Association of Social Workers formed in 1955,
helping unite the profession through guidelines and a code of ethics that defined roles and responsibilities
associated with social work practice.

101

America’s War on Poverty: 1960 to 1967

The 1960s was a time of social unrest and political change in the United States. With the Vietnam War
escalating, students and like-minded individuals protested the war across the country. Other movements
formed to protest against the lack of rights for women, people with physical and mental challenges, gay
people, and people of color. It was the civil rights movement that educated Americans on the extent of
prejudice and discrimination in our society and its costs. Books such as Michael Harrington’s (1962) The
Other America made the issue of poverty a public concern and a rallying point for citizen protests.

Exhibit 2.1 Programs Instituted With the Social Security Act

Source: Adapted from “Social Security Timeline” (n.d.).

President John F. Kennedy’s New Frontier and President Lyndon B. Johnson’s Great Society programs were
federal responses to issues such as these. Both administrations spoke of poverty and instituted a variety of new
social welfare initiatives, including Head Start, a program providing preschool education for disadvantaged
children; Medicaid, health care for the poor; Medicare, health care for older persons; and the Food Stamp
program, a food purchasing program for needy people. Exhibit 2.2 lists some of the programs from this era
that have had a lasting effect on social welfare.

A greater number of baccalaureate-level social workers were needed to fill the increasing demand for trained
staff as these programs were established. The National Association of Social Workers and the Council on
Social Work Education began accepting the Bachelor of Social Work as the entry-level professional degree in
the field.

Tired of civil turmoil and the Vietnam War, Americans turned politically conservative and embraced the
conservative ideals and concern with civil order promised by Republican President Richard Nixon (1969–
1974). President Nixon left the presidency after his participation in the cover-up of the Watergate scandal, a
breaking-and-entering scheme at the headquarters of the Democratic National Committee in the Watergate
Hotel in Washington, D.C. Vice President Gerald Ford became president (1974–1976) and eventually lost
his election bid to one-term Democratic President Jimmy Carter.

Although President Carter (1977–1981) promoted social programs and showed compassion for

102

disenfranchised Americans, his administration was marred by high inflation rates, spiraling gas prices, and an
international crisis involving the taking of American hostages in Iran. These events contributed to President
Carter’s political demise and failure to gain reelection, while setting the stage for the election of President
Ronald Reagan.

Jubilant American soldier hugs English woman, as happy service men and civilians celebrate Germany’s
unconditional surrender at Piccadilly Circus, London.

Source: National Archives photo no. 531280

Current Trends

103

Social Movements
As stated by President Lyndon B. Johnson, the goal for the nation’s involvement in Vietnam was not to win the war but for U.S.
troops to support defenses until South Vietnam could take over. By entering the Vietnam War without a clearly stated goal to win,
Johnson set the stage for future public and troop disappointment when the United States found itself in a stalemate with the North
Vietnamese and the Viet Cong (Rosenberg, n.d.).

1. Several movies depict the Vietnam War. Watch one of them and consider why social movements emerged from the Vietnam
War that changed the way many people think about military service and issues of society.

2. What similarities does the nation’s current involvement in Iraq and Afghanistan share with the Vietnam War?
3. What, if any, is the impact of voluntary military service on social movements about war?

Exhibit 2.2 New Frontier and Great Society Programs

104

Reaganomics: 1981 to 1989

In 1980, the Republican presidential candidate, Ronald Reagan, beat the incumbent President Carter with a
conservative platform that emphasized individual responsibility for one’s own problems rather than the reform
of existing systems for social welfare. Reagan called for a smaller federal government, a safety net for only the
truly needy, and a lifetime limit on social services. He also embraced trickle-down economics (a version of
classical economic theory also known as supply-side economics). The underlying idea was that reducing the
tax obligations of the rich would stimulate them to spend more on the consumption of goods and services. In
theory, the prosperity of the rich would “trickle down” to middle-class and poorer Americans via the creation
of new industries and jobs. There was, however, nothing to prevent the rich from simply holding onto their
profits, purchasing existing enterprises, or investing in enterprises overseas.

President Reagan’s administration was largely successful in implementing his vision. It shrank government
and social welfare programs and services at the federal level through budget cuts and the implementation of
means-tested programs and services. It also curtailed programs sanctioned and funded by the Social Security
Act, such as Medicaid, food stamps, loans for higher education, and legal assistance for poor people. To offset
these federal reductions and maintain some programs and services, many states and communities increased
taxation.

After President Reagan’s two terms in office, the 1988 election of his vice president, George H. W. Bush, to
the presidency continued Reagan’s conservative approach. President Bush focused his energy on international
affairs, showing little inclination to address social issues or domestic policy. Responsibility for social programs
shifted from the public to the private sector. President Bush promoted a “thousand points of light” campaign,
where communities would develop and often privately fund services and programs to address local needs.
Impoverished communities had few resources to dedicate to such points of light, however.

Pushback against the nation’s conservative era came by way of the election of William Clinton. President
Clinton (1993–2001) was the first Democratic president since Franklin D. Roosevelt to win a second term of
office. In revamping the welfare system, Clinton engaged in political compromise. One result was the 1996
Personal Responsibility and Work Opportunity Reconciliation Act, which reversed six decades of federal
policy guaranteeing at least a minimum level of financial assistance, or a safety net, for indigent people.

105

Partisan Gridlock

After a two-term Clinton presidency, Republican George W. Bush won the 2000 election. It was one of the
closest and most controversial presidential elections in history, and was ultimately decided in the Supreme
Court. A prior governor of Texas, President Bush described his political philosophy as “compassionate
conservatism,” a view that combined traditional Republican economic policies with concern for the
underprivileged. His administration targeted education and volunteerism within faith-based and community
organizations as a way of providing social services to the needy.

However, it was not domestic issues that marked the Bush administration. On September 11, 2001, terrorists
attacked the World Trade Center towers in New York and the Pentagon in Washington, D.C., by flying
passenger jets into them. A fourth suicide flight, en route to the White House or the Capitol building, was
thwarted by its passengers. All in all, some 3,000 people died. The event, now referred to as 9/11, defined
Bush’s tenure (see www.history.com/topics/9-11-attacks). He declared a “war on terror” and launched two
wars in the Middle East. He also established the Department of Homeland Security, a vast bureaucracy
charged with preventing any attack on the United States in the future. At the same time, he maintained his
pledge to reduce taxes. The result was a huge national debt, a faltering economy, and a national and
worldwide credit crisis.

The effect of many of his social initiatives was dwarfed by the wars in Iraq and Afghanistan, the fight against
terrorism, and the global war on terror. By the end of his term, President Bush had a public approval rating of
20%, the lowest recorded for any sitting president (Pew Research Center, 2008).

The 2008 election was remarkable for the victory of Democrat Barack Obama, the first African American
president. During the campaign, Obama had proposed a platform of change and reform in Washington, with
domestic policy and the economy as central themes. In the midst of a downward spiral in the national
economy, which became known as the “Great Recession,” he had several serious domestic and international
issues to address: the transgressions of Wall Street, America’s financial district, and the damage to the world
economy; burgeoning, and suspect, foreclosures on American homeowners; a dysfunctional and unfair health
care system; costly wars in Iraq and Afghanistan; increasing dissatisfaction with immigration policy; and
increasing signs of global climate change. The Obama administration experienced intransigent pushback on
nearly every issue from the Republican members of the House of Representatives and the Senate, who were
committed to a smaller federal government and a reduction in the national debt.

The transition of power in the presidential election.

106

Source: The Washington Post/Contributor/Getty Images

The Obama administration’s signature social welfare policy is the Affordable Care Act (ACA), signed into
law on March 23, 2010. A controversial piece of social welfare policy because it expands the role of the federal
government, the policy enacted comprehensive reforms to improve access to affordable health coverage and to
alter insurance company practices. Ideally, the ACA will decrease the nation’s health care costs and make
insurance companies more accountable for how premiums are spent.

The ACA primarily affects health care coverage in three ways: through health exchanges, which went into
effect in 2014; by expanding Medicaid coverage; and when states decide to create their own basic health
programs. In each case, social workers will help people “navigate” the new systems of health care to ensure
they receive proper coverage and benefits. Further, the expanded health care provisions address mental or
behavioral health, which represents another significant service area where social workers play a vital role.

Donald J. Trump shattered expectations on November 9, 2016, with an election night victory over Hillary
Clinton that revealed deep antiestablishment anger among American voters. President Trump achieved one of
the most improbable political victories in modern American history, despite a series of controversies that
would easily have destroyed other candidacies, extreme policies that have drawn criticism from both sides of
the aisle, and a lack of conventional political experience (http://www.huffingtonpost.com/topic/trump-
administration).

Why did Trump win the election? It appears as though key groups of voters overlooked his personal character
and political shortcomings and instead embraced him as an agent of change against corrupt government
officials who seemed to pay more attention to the poor than to the middle class.

To keep his campaign promises, President Trump’s administrative agenda highlights several key issues that
will result in subsequent changes in policy and budgetary allocations. Included on the agenda are efforts to

Rebuild the military to give America a firmer footing in pursuing peace through strength.
Withdraw from the Trans-Pacific Partnership and renegotiate the North American Free Trade
Agreement.
Propose a moratorium on new federal regulations, along with an order that heads of federal agencies and
departments identify regulations that challenge employment opportunities.
Deport illegal immigrants with violent criminal records.
Safeguard Second Amendment rights.

President Trump’s biggest challenge involves the ACA, which he vowed to repeal and replace. When he took
office, approximately half the population was covered by employer-sponsored health insurance, with the other
half covered by Medicare, Medicaid, and individual private insurance (Miller, 2016). Changes in the ACA
will alter health care coverage for the most vulnerable people, those being covered under Medicaid. Some
health policy analysts believe the ACA’s employer mandate might be repealed in the fiscal year 2017
reconciliation bill, meaning it would influence the parts of the ACA that have to do with federal funding. It
would pertain to massive parts of the law, including Medicaid expansion, the mandate that everyone must buy

107

insurance, and all taxes and tax credits under the law. The ACA then might be replaced in a fiscal year 2018
reconciliation bill.

Time to Think 2.5

What stands out in your mind as you consider the development of social work and social welfare policy over time? What seems to
drive the development of social welfare policy?

Is there a point in this history that you find particularly interesting? Why? What are the significant events in the development of the
social work profession that draw you to consider social work as a career option?

108

The Limitations of Social Welfare

Although social reforms have enriched the lives of millions of Americans (Jansson, 1999), they sometimes fail
to meet stated or ideal goals. Consider how the notion of the “deserving poor” has affected the provision of
social welfare. Our belief in supporting children and older people has characterized American society since
colonial times. This fact sends a strong social signal to families that they should be responsible for their own.

Most of the social services that target young and old age categories are crisis interventions rather than
preventions. For instance, policies such as the Social Security Act and Temporary Assistance for Needy
Families provide a safety net for children and older adults. However, the basic needs of food and clothing are
met in a modest fashion under the guise of cost containment. In such an environment, clients live with
uncertainty and the practice of social work is restricted.

Although the United States is a rich country, many people are working hard every day but living from
paycheck to paycheck. Far too many Americans live in poverty, relying on social programs for their most basic
needs. Ideally, changes in social policy would give these underprivileged groups greater access to jobs that pay
a living wage and equip them with the tools, such as a good education, to raise their status in society.
However, the nation’s social welfare system does little to move working-class and poor people from their
current socioeconomic class.

Tellingly, some communities experience persistent poverty and social inequality. In America, these groups are
often the victims of racism. There are no policy examples and few social service programs that draw from and
honor the cultural backgrounds and personal experiences of people of color. How can the effects of racism be
challenged by the profession of social work? The history of social welfare policy suggests the need to address
the root causes of social, economic, and political inequality. The 1963 March on Washington, followed by the
1964 Civil Rights Act, demonstrated that organizing people and taking united action can change the course of
a nation.

For a more recent example of how movements for social justice can change society, consider the evolution of
sexuality-based issues. History illustrates a long, hard struggle among women, lesbians, and gays for equality
in all spheres of American life. Individually and collectively, they have been actively involved in civil rights.
Through resilience and resourcefulness, this broad-based population has tackled barriers to its own growth
and participation in society. Subsequently, political institutions, American corporations, families, faith
organizations, and other major American entities have changed power arrangements to ensure a greater degree
of equality.

Time to Think 2.6

What social issues concern you? Do you have student loans or pay taxes? Are you concerned about the environment, affordable
health care, voting rights, military engagement, immigration, net neutrality, or legalization of marijuana?

What action could you take to influence a policy or concern? Do you see the federal government as a vehicle to address your
concerns? What is your role in bringing a particular issue to the public’s attention? For example, do you vote, volunteer for

109

campaigns, post to blogs, call in to radio shows?

Are organizations on your campus or in your neighborhood working on social issues? Have you participated or will you participate in
such an organization? Why or why not?

Summary

Approaches to social welfare have changed over the past few centuries of American life, and the social work profession has evolved
alongside those changes. However, despite improvements in many realms of life, the problems to which social welfare responds have
remained.

There is a rhythm of social responses to social welfare problems and social issues. As this chapter indicates, economic ups and downs,
wars, political shifts from conservative to liberal perspectives, and attitudes toward individual responsibilities are all factors that
influence development of the social welfare system. The result is a fragmented approach to addressing human needs.

Currently many issues are facing the social welfare system. Debates over the nation’s health care system and immigration policies, for
instance, continue as cutbacks are made in programs to assist those in need. Determining how to intervene in issues such as these has
always been a problem for our nation. This is particularly true in relation to providing assistance for those who are poor and appear
to be able to work. Much depends on our willingness to commit to helping those in need.

110

Top 10 Key Concepts

conservative
deserving poor
liberal
means testing
nondeserving poor
safety net
social control
social justice
social welfare
social welfare policy

111

Discussion Questions
1. Think about your political ideologies and where they came from throughout your lifetime. Do they align with your parents’

ideologies? Is this an issue? Why or why not? What experiences formed your opinions on social welfare services and social work?
2. As you read through the history of the development of social work, what period of time most captured your attention? What is it

about this time that piques your interest?
3. Define the current political scene, environmental conditions, human needs, and social justice issues in the United States or your

country of origin. How have these factors contributed to debate on a policy issue and a specific social welfare policy?
4. Take time to review Exhibit 2.1, the Social Security Act timeline. Discuss the issues and actions you think have been the most

effective in helping the needy.

112

Exercises
1. Learn more about various political parties and their stances on social welfare by going to their websites. In addition to the

Democratic and Republican parties, seek information about the Libertarian Party, the Green Party, the Progressive Party, the
Constitution Party, or others that run candidates in your locale. Focusing on the issue of social welfare, locate the parties on a
spectrum from most liberal to most conservative.

2. Read an editorial from one of the nation’s leading newspapers or news websites. What political perspective does the editorial
reflect, and how did you reach this conclusion?

3. Role-play a situation in which you must ask for public assistance. How did you feel about being in need and asking for help?
4. Create a policy timeline using the periods of the Elizabethan Poor Laws, colonial America, the Progressive Era, the Great Depression,

the War on Poverty, the Great Society, Reaganomics, the period of reforming the welfare state, the Obama presidency, and the Trump
administration. Select one landmark event from each period and read about the relevant political situation, environmental factors,
human needs, and social justice issues of the time.

5. Choose a social welfare service available in your community. Gather the history of this agency. In what ways does its history
compare to what you read in this chapter?

Online Resources

Great Depression (www.history.com/topics/great-depression): Defines the Great Depression and how it impacted the lives
of people. Provides text, images, and video about the era that launched many new social programs
Settlement movement (www.cfsettlements.org): Examines how the movement changed public health and working conditions
for many workers
Social Security Act (www.ssa.gov/history/pdf/histdev.pdf): Considers the significance of the Social Security Act from a
historical perspective and as a safety network for Americans
Social Welfare History Project (www.socialwelfarehistory.com): Provides more information about the Charity Organization
Societies and other relevant topics
Social Work Pioneers (http://www.naswfoundation.org/pioneers/): Describes social work leaders and advocates in the
context of their contribution to the profession
War in Vietnam (www.history.com/topics/vietnam-war): Covers the relevance of the war in terms of public unrest
White House website (https://www.whitehouse.gov/): Provides an updated list of the administration’s social welfare
priorities and associated activities

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

113

Chapter 3: Generalist Social Work Practice

Source: © iStockphoto.com / KatarzynaBialasiewicz

114

Learning Objectives
After reading this chapter, you should be able to

1. Describe the knowledge base for generalist social work and direct practice.
2. Describe the five theoretical bases of generalist practice.
3. Explain the purpose of the National Association of Social Work Code of Ethics.
4. Define roles available for generalist social workers.
5. Identify the five steps in the client change process.
6. Explain how the advocacy program and policy model applies to the change process.
7. Explain how generalist social workers can advocate for change across client systems.

Layla Intervenes at All Levels to Help People Who Are Homeless

Layla, a BSW social worker, is employed in a homeless shelter for men in a metropolitan area of the United States. She assists clients
to find employment and permanent housing. She also makes referrals to health and dental clinics. Layla thinks that the people she
works with have great potential as long as some of their basic needs are met on a regular basis. For this to be accomplished, Layla
realizes she needs not only to assess particular individual needs but also to consider issues that affect groups and entire communities.
She begins to network with faith-based organizations, community social service agencies, and business associations with the hope of
better understanding the ways advocacy and community support can enhance opportunities for the men living in the shelter. Layla
also gathers ideas from the shelter’s clients on ways the broader community can offer to support them. What emerges from the
conversations is the idea of a client council from which people can begin to advocate for themselves.

This chapter highlights generalist social work practice. The goal of generalist practice is to address
problematic interactions between persons and their environments or surroundings. Most helping relationships
and change situations within social work involve generalist skills. A generalist social worker may work in
schools with children who have learning challenges, people living in an institution who need help adjusting to
life outside, on the street with destitute families who need immediate assistance with housing and food, with
older people who can take care of most of their daily activities but need assistance with health care insurance
and prescribed medications—or with any number of other types of clients. Community members who are
organizing for change in their living environment, such as people fighting to reduce air pollution in their
neighborhood, may also rely on a generalist social worker to help facilitate their efforts in the political arena.

The knowledge, theoretical perspectives, roles, and skills of generalist practice are described in this chapter.
You will see that generalist social workers, including those with a bachelor’s degree in social work, have an
array of employment opportunities. Social workers confront problems ranging from individual issues, such as
domestic violence, to community issues, such as lead paint poisoning in federal housing projects, to national
issues, such as gun violence and voting rights. Not all problems can be solved by generalist social workers, but
they do possess the skills to assess many types of situations, plan a course of action, and evaluate outcomes.

Generalist social workers work with individuals and families to assess their needs.

115

Source: ©iStockphoto.com/vuk8691

This chapter emphasizes direct practice, or one-on-one interactions with clients. The social work profession
has an important role to play in helping clients attain more social power, resources, and services. A generalist
social worker needs problem-solving skills and the ability to determine a client’s strengths or potential to
participate in a change effort. Generalist social workers must also be able to think beyond current situations
and to devise change strategies that build on strengths and capitalize on existing and potential resources.
These skills are central to social work practice at the generalist level.

116

Knowledge Base For Generalist Social Workers

The Bachelor of Social Work (BSW) degree, as Chapter 1 explains, is the entry-level credential for the social
work profession. (In many states across the nation, baccalaureate social workers must also pass a state required
examination to become licensed to practice.) The BSW degree provides the knowledge base for generalist
social work practice. Although not required, membership in the National Association of Social Workers, the
largest professional organization for social workers, helps generalist practitioners continue to learn and add to
their knowledge bases throughout their careers.

The education for generalist practice is based on the liberal arts, a curriculum that provides a general fund of
knowledge and academic skills. Courses within the liberal arts foundation that apply to a social work degree
vary from university to university, but typically courses from sociology, psychology, biology, economics,
political science, and statistics are included. The liberal arts foundation introduces students to the idea that a
thorough understanding of a society, its people, and the challenges they face depends on knowledge, attitudes,
ways of thinking, and means of communication. In addition to the required liberal arts courses, generalist
social workers also take courses in the following subject areas:

Human behavior in the social environment: Course material examines theory, research, and practice issues
related to human development. Emphasis is placed on understanding the relevance and use of theory in
practice, and the way diversity—such as in gender, race, ethnicity, sexual orientation, and economic
circumstances—contributes to and influences personality development.
Social work research: This course covers the formulation of research questions, data collection, and data
analysis. Students are taught both to consume and generate research findings that support conclusions
about life conditions. Most research courses introduce classic and contemporary studies, and point out
how their findings apply to social work knowledge and practice.
Social policy: Courses in this content area examine the nation’s social welfare system and the
development, implementation, and evaluation of policy. The social welfare policy course informs social
work students of available services and programs, as well as which people are eligible for services and
how long services can be provided.
Social work methods or practice: These courses present a conceptual framework for social work
intervention and cover common elements of social work practice, such as the social work process and the
interaction of various kinds of diversity. Students are introduced to concepts and skills relevant for
practice with individuals and groups, and in a variety of community settings.
Field education: A requirement of all social work students, field education involves a placement in a
social service agency, where students are required to complete at least 480 hours under the supervision of
a master’s-level social worker. Field education connects knowledge from the classroom with the
opportunity to apply practice skills and knowledge in an agency setting with an array of clients.
Electives: Social work students usually have the opportunity to select courses that complement their
social work curriculum and expand on social welfare or social work issues that interest them. Electives
may focus on addictions, domestic violence, international social work, aging, child welfare, or anything

117

else that relates to today’s social needs.

Exhibit 3.1 diagrams the interplay of these elements of the baccalaureate social work degree. Given the
complexity of the problems they address, social workers need a broad knowledge base to develop a toolbox of
interventions that can be used to undertake a change process.

Throughout the social work curriculum, students are repeatedly exposed to the profession’s code of ethics and
core values, which highlight human rights and social, economic, and environmental justice. Social work’s
commitment to self-determination—the right of people, groups, and communities to make choices, design a
course of action, and live as independently as possible—is stressed repeatedly.

Time to Think 3.1

Ethical behavior is a critical concept in generalist social work practice. Review the National Association of Social Work Code of
Ethics, with a particular focus on Section 3 (NASW, 2018). To what degree has ethical behavior influenced decision making in your
life on issues related to relationships, activities with friends, and college life?

Consider how ethics have caused you to think through options, evaluate alternatives, and solicit ideas from others. What have you
learned about yourself in terms of ethical behaviors?

The baccalaureate social work curriculum also acts to expand students’ skills in critical thinking—the ability to
reflect on and integrate information from an array of sources to form a position, opinion, or conclusion. This
is a critical skill for generalist social workers, who need to be able to express their views confidently and
support them when questioned.

118

Theoretical Foundations of Generalist Practice

Generalist practice is a comprehensive, multidimensional approach to social work that draws from a variety of
intervention models and theoretical perspectives. Some of their concepts and content are taken from biological
science, psychology, sociology, and political science. Five of the most useful theoretical foundations for the
generalist social worker are systems theory, the ecological perspective, empowerment theory, the strengths
perspective, and evidence-based practice.

119

Systems Theory

Social workers engage in practice with individuals, groups, communities, and organizations. The multifaceted
interactions that social workers encounter demand a comprehensive view of the world in all its complexity.
The knowledge of systems theory facilitates a dynamic understanding of client interactions from various
perspectives and in several settings.

To understand systems theory, begin by thinking of a system as a collection of elements, members, or parts of
a larger whole. For example, a client system might consist of an individual; important family members and
friends; relationships with work, church, and other organizations; and elements of large-scale institutions such
as the economy. These elements are like pieces in a puzzle. For the puzzle to be complete or whole, the pieces
must fit together in relation with one another. The interrelationship of puzzle parts is essential, because they
come together to make the entire picture. For the client system in the example, the individual’s problems and
the solutions to those problems are seated in all the elements of the system. In a similar fashion, the elements
that shape your life—your family, friends, college, and home community—reflect who you are and how you
function as a whole person. These various elements are essential to your being and your ability to succeed in
numerous circumstances. Exhibit 3.2 is an ecological map, a type of diagram that social workers use to
represent a client system.

Exhibit 3.1 Knowledge Base for Baccalaureate Social Work

120

Parents and children are a part of a client system, which social workers using systems theory may use to help
their clients.

Source: iStock Photo / monkeybusinessimages

Social Work in Action

121

Issues in Domestic Violence

122

Attention on Strengths
Cole is a social worker at a domestic violence center that services primarily residents from the suburbs of a midwestern metropolitan
area. George, a client, came to Cole about his inability to manage the anger he expressed toward his wife of 10 years and their two
children, a girl of 8 and a boy of 5. Up to that point in time, George had not engaged in any physical violence toward his family, but
he did punch a wall, destroy property, and threaten harm. George’s wife had threatened to divorce George unless he curbed his angry
outbursts.

Through conversations and role plays, Cole encouraged George to consider his life stressors. Over several sessions George came to
realize that his anger stemmed from increased work pressures coupled with a decrease in salary and prestige. In fact, people younger
than George were being promoted over him. Cole facilitated a process whereby George began to reflect on his strengths. Interesting
enough, George concluded that his wife and children were sources of strength for him, as was his educational status.

George would like to thank Cole for his supportive services by taking him to lunch. Cole respectfully declines the kind offer.

1. Why would assessing personal strengths be helpful when attempting to manage anger?
2. How does age play into George’s circumstances?
3. What strategies did Cole use to facilitate George’s assessment of his life situation?
4. What do you suggest Cole should do next to help George control his anger?
5. Explain why it was necessary for Cole to decline George’s lunch invitation.

Social workers use systems theory to conceptualize all the elements of complex human problems and to
introduce a change process. It allows for a multidimensional analysis of function, cause, and interrelations
when considering avenues of change. For example, Pam is a single mother of three school-age children.
Recently unemployed, Pam needs to find work to support her family in their small rental home. Although
Pam has multiple challenges, she is optimistic and hardworking, with good parenting skills. A social worker
would visualize Pam’s interrelated system by considering her problematic life elements and unique resources as
a network of patterns, purposes, and attributes. Thus, systems theory provides social workers with a backdrop
for practice that recognizes complexities, strengths, and avenues for change.

Time to Think 3.2

List the major systems that compose your life. Are any of the systems in conflict with one another? What impact does that conflict
have on you?

The systems approach, which has been applied to disciplines from engineering to psychology, as well as social
work, takes into account not only the complexity but also the dynamic nature of the interactions among the
elements in a system. The interactions involve input, a process of change, and output (see Exhibit 3.3). In
social work, input takes the form of communication patterns between people, information transfer, and
knowledge acquisition. Output takes the form of attitudes, behaviors, and role performance. The change
process reflects the impact of the input on elements of the system and results in output that is noticeably
different from the input and the elements at the beginning of the process.

It’s important to keep in mind that human systems are always interacting with other systems, and inputs and
outputs are continually changing those interactions. Consider the impact of the exchanges between a parent
and a child, a student and a school, a family and a community, an employee and a workplace. The give and

123

take in these relationships provides you with an idea of the reciprocity of interactions and the process by
which people engage in the world around them.

Exhibit 3.2 Client System Represented in an Ecological Map

124

Ecological Perspective

Concepts from systems theory provide a foundation for the ecological perspective, which focuses on people
and their environments. Those environments comprise the physical and social settings where a person resides
or experiences life situations, including families and neighborhoods, communities and workplaces, and culture
and institutions, such as places of worship and the education system. They are all part of a person’s
environment.

Generalist social workers learn to think of people as constantly interacting with their environment, a habit of
mind called the person-in-environment perspective. It highlights how people are affected in positive and
negative ways by their surroundings. Consider what it was like when you graduated from high school and
entered college. You were faced with new circumstances, conditions, and expectations; however, you adapted
to the change and soon found yourself comfortable in your new surroundings. This process of adaptation is
critical to ecological or person-in-environment concepts. Adaptation requires the input from new ideas and
experiences and the output of energy in the form of effort and flexibility. Fortunately you were successful in
your adaptation to a new educational environment.

Exhibit 3.3 Client System With Inputs and Outputs

Social workers assess their clients’ various day-to-day interactions.

125

Source: iStock Photo / SolStock

Exhibit 3.4 illustrates the elements of the environment that usually affect a person or a problem. Generalist
practice with a person-in-environment perspective involves assessing all these elements of the environment:

Political–economic system: Laws, political atmosphere, ideological trends, economic health
Faith-based organizations, the marketplace, and human service systems: Providers of the resources
(goods and services) that can be tapped to sustain a good life
Education and employment systems: Developers and users of human skills, which promote well-being
by giving people a place in society
Family, fictive kin, and social support systems: The “home base” of friends and family (however family is
defined by the individual) that provides a sense of safety and security and shapes the person’s emotional
life

The ecological and person-in-environment perspectives emphasize dynamic and complex relationships within
an environment. Social workers understand that some people struggle with adaptation to changes in the
environment and need help in the process. Social workers also recognize that sometimes the environment
needs to be changed to better suit the needs of a person. Sometimes improvements in social functioning
correspond to change in social structures.

Time to Think 3.3

The ecological and person-in-environment perspectives might be unfamiliar to you; people often blame personal qualities for their
difficulties. Take a moment to think about how the concepts and terminology of the ecological perspective apply to your world. How
has your community supported you throughout your development? Were you a member of a neighborhood sports team or club, such
as a scout troop, or of some other supportive group while you were growing up? Was a place of worship significant to you as a child?
What was missing from your community that you would like to add to the surroundings of other young people? Why?

126

Empowerment Theory

A key term in both systems theory and the ecological perspective is change—change in individuals, families,
groups, communities, organizations, institutions, and societies. Empowerment theory is a set of ideas that
generalist social workers use to increase change possibilities. Social workers do not just provide the resources
that people need; rather, they help people access resources on their own. Empowerment provides people with
the means to attain their goals either directly or indirectly, through the help of others, such as social workers.
Empowerment links the strengths and potential of individuals, systems, and behaviors to social action and
societal change (Rappaport, 1981). For example, an empowered individual might challenge workplace
promotion policies. A community can be empowered because citizens unite to improve conditions and the
overall quality of life in their neighborhood.

A transformation occurs through the empowerment process. As individuals, families, and communities
enhance their capacity, they begin to feel a sense of control over their lives as well as their environment. Thus,
empowerment involves not only outward changes but also inward changes in self-esteem and the sense of
personal value.

As a strategy for social work practice, empowerment necessitates collaboration with informal groups, such as
family and neighbors, and formal networks, such as agencies and organizations. The result is collective power
that maximizes existing strengths and resources while tapping potential sources of renewal and change.

Exhibit 3.4 Person-in-Environment Perspective

Closely connected to empowerment is advocacy, which in generalist practice encompasses all the activities that
influence the allocation of resources and the decision making that occurs within social systems, institutions,
and the political and economic arena. Influenced by a vision of a just society, social workers often find
themselves questioning “why things are the way they are” and considering “what should be.” That is the point
where advocacy begins.

127

The empowerment aspect of advocacy links personal and political power to promote systematic societal
change. Consider the dramatic societal change in support of marriage equality. It began when gay and lesbian
individuals, seeking the rights and benefits of marriage, made their wishes known through the media and in
public demonstrations. In moving from hopes and dreams to action, they accepted and embraced their
sexuality, became empowered personally, and were able to organize a network of people and organizations that
supported their position. The empowered gay and lesbian community successfully advocated at the local, state,
national, and international levels for structural change to societal practices.

LGBT Pride events create a space for individuals in a community to advocate for change and show support.

Source: Anadolu Agency / Contributor / Getty Images

Using advocacy as a vehicle for empowerment supports social justice, which is a key concern of social workers.
Social justice exists when everyone in a society shares in civil liberties, has a voice in political affairs, and has
equal access to resources and opportunities.

128

Strengths Perspective

The cornerstone of generalist social work practice is the ability to assess and address problems related to
people, groups, communities, and organizations. Although social workers recognize that problems do
challenge clients, sometimes grievously, they also recognize that clients in their environments have strengths,
assets, resources, and knowledge that may be useful in solving those problems. The strengths perspective gives
credence to the idea that every person has strengths to call on in solving their problems (Saleebey, 2009).

Changing one’s environment, or the way one interacts with the environment, can have positive results.

Source: iStock Photo / PeopleImages

Central to the strengths perspective is the role of assessment. Of course, in direct practice social workers assess
their clients’ situations. In addition, the clients themselves are also called on to define or assess their
conditions and state what they would like to change. In this way clients are empowered to act on their own
behalf in conjunction with social workers. The resulting shift in power places clients in a prominent position
in the helping relationship.

How does the strengths perspective manifest in generalist practice?

Listening to the ideas of clients and communities to identify resources and opportunities
Collaborating with clients as an equal partner in the assessment and change process
Recognizing the unique potential and resilience of clients to challenge barriers
Understanding that communities offer untapped resources that can be used individually and collectively

The strengths perspective complements systems theory, the ecological perspective, and empowerment theory
by making people the primary experts in their own change processes (Saleebey, 2009). It ensures that the
outcomes of change will reflect the needs and concerns of clients. The usefulness of the strengths perspective
is in the values implicit in its approach and the direction it offers to social workers tackling a case or cause.

129

Evidence-Based Practice

The goal of evidence-based practice (EBP) comprises four features: (1) the client’s situation; (2) the client’s
goals, values, and wishes; (3) clinical expertise/expert opinion; and (4) external scientific evidence. As is
apparent, the client is an active participant throughout the intervention planning, implementation, and
evaluation.

The use of EBP is thought to correlate with positive results in a selected intervention and the overall change
process. Some social workers place emphasis on the findings derived from large-scale experimental
comparisons to document the effectiveness of intervention against a control group that did not experience the
intervention. In this way, the notion of cause and effect is approached. Other social workers honor the
evidence generated from nonexperimental research, suggesting that some experimental research is too narrow
and limited by conceptualizations, measures, participant samples, and specified interventions.

Generalist social work often describes EBP in the context of the decision-making process. The use of EBP is
one way to help ensure that clients receive the best services possible. It also embraces a professional
commitment by social workers to understand and critically appraise data from a variety of sources. Overall,
adoption of EBP and current research findings upholds professional practice standards and serves as a means
for practitioners to inform the course of social work research.

Time to Think 3.4

Generalist social workers use all five of the theoretical foundations outlined here—systems theory, the ecological perspective,
empowerment theory, the strengths perspective, and evidence-based practice—to help clients address the issues in their lives. Think
of a time when you felt locked into a difficult set of circumstances. How would each of these foundations have helped you overcome
those circumstances?

130

Roles For Generalist Social Workers

People enter the social work profession for numerous reasons. Some want to make a difference in people’s
lives; others received services or care at some point in their own lives and want to give back as a form of
reciprocity. The overriding reason is that people who enter social work care deeply about people, the
conditions they live in, and the opportunities available to them.

As Chapter 1 explains, baccalaureate-level social workers are prepared to practice with individuals, families,
groups, organizations, and communities in entry-level positions in social service agencies, child welfare
bureaus, shelters, community organizations, faith-based programs, schools, health clinics and hospitals,
mental health and treatment centers, and criminal justice facilities. The types of clients encountered in these
settings vary, as do their immediate issues, but in all cases the social workers’ primary role is to be of assistance
and service to people in need.

The specific roles of generalist social workers reflect how they see themselves and are viewed by others.
Although it is difficult to comprehensively define all the roles of social workers, the following list is a good
sampling:

Advocate: Champions the rights of others with the goal of empowering the client system served
Broker: Assists clients in identifying, locating, and linking to needed resources; establishes a network of
services and providers in collaboration with clients
Case manager: Oversees the services provided to clients to ensure that their needs are met through
quality interventions and in a timely fashion
Counselor: Provides direct services that help clients articulate their needs, problems, and goals; explores
options and strategies for change in light of the clients’ strengths and resources
Mediator: Intervenes in and resolves disputes in a fair and equitable fashion; finds common ground,
compromises while reconciling differences, and assumes a neutral role
Navigator: Assists clients in maneuvering through complex bureaucracies, such as the health care
system, to gain needed services
Researcher: Conducts research projects and program evaluations to gain evidence that informs practice
and policy

131

Levels of Generalist Practice

Chapter 1 also introduced the levels of practice at which a generalist social worker might intervene. Here we
can take a closer look at them and at how they may be expressed in generalist practice.

132

Social Work with Individuals (Micro Level)

This level of practice is often also referred to as direct practice. Social work with individuals one-on-one
requires skills in communication, cultural sensitivity, empathy, genuineness, and solution-focused decision
making. Refined assessment and interviewing skills (discussed later in the chapter) are also necessary to get
people to trust you and open up about their deepest concerns and needs.

To be an effective social worker at this level of practice, you must strive to know yourself well. Social workers
consciously use their selves as a tool to engage clients, by seeking areas of commonality and offering insights
into differences. Social workers also rely on their sense of themselves to demonstrate healthy professional
boundaries—that is, to show clients how the social worker can help and which activities the social worker
cannot perform with clients.

Current Trends

133

International Expansion of Generalist Practice
Countries such as China, Mongolia, Taiwan, and Vietnam are seeking social workers to develop educational programs in social work
and to design social service networks and programs. Often the programs are associated with national problems such as child abuse,
substance use, and health care issues, including HIV/AIDS, tuberculosis, and malaria. Most of these countries are in the
development stage of their economic base and welfare system.

1. Take a moment to read about the International Federation of Social Workers at ifsw.org. Then review some of the
international employment opportunities and list at least three possible trends you see developing for generalist social workers
on the international scene.

2. Why would developing nations seek support from U.S. social workers?
3. Do you think these international opportunities for generalist social workers are an option for you? Why or why not?

Time to Think 3.5

Take a moment to consider the unique strengths you have. How have you used your strengths to address a personal problem or issue
you’ve experienced?

Though social workers acknowledge clients’ challenges, they also understand the strengths, assets, and
resources available to them.

Source: iStock Photo / CasarsaGuru

134

Social Work With Families and Groups (Mezzo or Meso Level)

Social work with a family is very rewarding. It actually combines micro with mezzo practice because it
includes the family (a small group) in addition to the individuals that compose that family. Note that social
workers in the 21st century must be prepared to accept an array of different “family types.”

Sources and dynamics of social support must be fully explored when working with families. How well family
members provide emotional, economic, and day-to-day, practical support to one another matters. Social
workers need to look at those forms of support as immediate and highly effective resources that buffer stress
and facilitate clients’ adaptation to changing conditions.

Group work is another mode of intervention at the mezzo level. In generalist practice with groups, a social
worker may serve as a consultant, evaluator, facilitator, initiator, resource person, therapist, or a combination
of these. It can be a challenging task to wear so many hats at once; however, it is important to keep in mind
that group interaction, support, and interdependence have great potential to foster change, as group members
experience and lend mutual aid to one another. Support groups, family education groups, resident councils,
social or life skills groups, and anger management groups are all possible forums where social workers can use
group process or facilitation skills. But although social work educators teach group process skills to all
students, not all social workers identify group work as their primary practice area (Whitaker & Arrington,
2008).

135

Social Work With Organizations, Communities, and Society (Macro Level)

Macro-level intervention has always been a part of social work. It can be considered synonymous with
advocacy. The term macro has both general and specific connotations:

In a general sense, within social work, macro-level intervention means engaging with large systems in
the socioeconomic environment. Macro practice in this sense may include collaboration with individual
clients to strengthen and maximize their opportunities at the organizational, community, societal, and
global levels—what we have called case advocacy.
In the specific sense, macro social work practice suggests that the strengthening of higher-order social
systems (organizations, communities, societies) is the focus. This sort of macro practice is synonymous
with cause advocacy and community organizing (Rothman, 2007). It is this sort of macro-level work
that distinguishes social work from other helping professions (Glisson, 1994).

Indirect social work is another historical term that is synonymous with macro social work. This terminology is
outdated but was used to connote social work’s commitment to environmental change and the alleviation of
widespread suffering and social problems. In contrast, direct social work practice referenced face-to-face
contact with clients to support or strengthen them as people.

136

The Change Process

As social work became more professional, its practitioners and theorists developed a framework of steps that
would remind social workers about how they might best intervene in people’s lives and help them meet their
needs. The process begins when a social worker is assigned a client and does not end until the client–social
worker relationship, which often includes aftercare activities, ends. The following are typical steps or phases
identified in the change process:

1. Engagement
2. Assessment
3. Planning
4. Implementation
5. Evaluation

Although such frameworks are straightforward and work well to outline a general way activities occur in
practice, it is important to realize that actual interventions do not always occur in a step-by-step, linear
fashion. For example, implementation and evaluation may reveal that another round of assessment and
planning needs to occur.

Many social workers acknowledge that the client–worker relationship is critical to the change process. As
workers respond empathically to clients, warmth, genuineness, and trust are likely to develop over a period of
time. As a result, clients will feel comfortable to explore issues, provide comments, and map sources of action
that lead to change in their lives. Arguably, perhaps the most important component of the change process is
the client–worker relationship, which is based on a mutual bond of trust and confidence. Common steps in
the change process are further examined and described below.

137

Engagement

As the first step of the model, engagement sets the tone for the change process. The social worker interviews
the client (or clients) to learn as much as possible about the person in the context of his or her environment.
Skills in verbal and nonverbal communication are crucial for understanding clients and putting them at ease.
Engagement is a key time for people to get to know each other and begin developing rapport.

To interview well, you must know how to listen actively, guide a conversation, and be open to clients’ initial
and perceived needs. Flexibility is a key attitude to respond to different contexts and individual preferences
(Sidell & Smiley, 2008). There are many excellent books describing the relevance and importance of
interviewing skills (e.g., Benjamin, 1981; Hepworth, Rooney, Rooney, Strom-Gottfried, & Larsen, 2010;
Ivey, Ivey, & Zalaquett, 2010).

Exhibit 3.5 PERCEIVE Framework for Decoding Nonverbal Behaviors

Source: Adapted from Sidell and Smiley (2008, pp. 74–76).

Effective interviews that promote revealing conversation about fundamental issues possess several
characteristics (Evans, Hearn, Uhlemann, & Ivey, 2004; Sidell & Smiley, 2008). The interviewer must use
visual means of communication that are sensitive to the culture, gender, and personality of the interviewee,
such as appropriate eye contact, vocal qualities, and body language. Good interviewers are very skillful in
knowing how and when to use closed- and open-ended questions.

Empathy is often used in interviews as a way to feel and share another person’s emotions. In social work
practice, having empathy enhances the understanding that there are many factors that go into decision making
and cognitive thought processes. For example, an empathic approach recognizes that past experiences have an
influence on the decision making of today. Understanding this allows a social worker to consider an
individual’s lived experiences in a nonjudgmental fashion.

During interviews, decoding clients’ nonverbal behaviors is essential for successful communication. Some
interviewers like using the PERCEIVE framework (Beall, 2004; Sidell & Smiley, 2008, pp. 74–76).
PERCEIVE is an acronym for the types of communication behaviors the client may exhibit; see Exhibit 3.5
for the details.

For an example of how the engagement process might take place in an intervention, consider Angus, a

138

generalist social worker at a homeless shelter, and his client Hank. Angus begins by establishing a relationship
with Hank through communication that displays empathy for Hank’s current situation and concern as to what
Hank will do on the city streets when the weather grows cold. Angus passes no judgment on Hank’s spotty
work history or sketchy friendships. Rather, Angus spends time empathically listening to Hank’s story of a
recent apartment eviction and sense of failure as a retail clerk. Angus’s formal and informal questions and
willingness to discuss topics of interest to Hank place Hank in the position of expert (Tice & Perkins, 1996).
Angus also fosters Hank’s self-confidence by complimenting Hank on his strengths: his resilience and ability
to think ahead about the approaching winter.

It is important for generalist social workers to engage with their clients through empathy and recognition of
their strengths.

Source: iStock Photo / asiseeit

What slowly occurs between Hank and Angus is a collaboration or partnership. The engagement component
of the change process initiates productive patterns of communication and a mutual sense of confidence about
working together. In actual practice, forging client–social worker relationships often needs to be given priority
over the completion of agency forms and paperwork. Indeed, without a relationship, it is often difficult even
to collect client information.

139

Assessment

Assessment, the second step in the change process, is bidirectional in nature—a two-way street. The social
worker is assessing the problems and strengths of the client, while the client is assessing the personality,
professional skills, and demeanor of the social worker. These parallel assessments begin to intersect if they
build on positive engagement and remain nonthreatening. For example, Hank was pleased when Angus
endorsed his future plans and recognized his “can-do” attitude toward life. Sensing Angus’s acceptance made
it easier for Hank to discuss some of the problems that extended beyond his homelessness and included a
description of sensitive and fragile relationships with his family. Some of Hank’s other unique strengths were
quickly apparent to Angus. Hank was resourceful, creative, and articulate. He was willing to accept feedback
in a positive manner and reflected on options related to his situation.

During assessment, the generalist social worker also begins connecting individual or micro problems with
macro or broader aspects of the situation. In Hank’s case, Angus knew the city had a shortage of affordable
housing. Many residents lived with the fear of homelessness, especially if an unexpected financial crisis
resulted in an inability to pay the monthly rent or mortgage installment. Working with Hank on his
individual need for permanent housing connected both Hank and Angus to the larger issue of an affordable
housing shortage throughout the city.

Another broader aspect of the situation was Hank’s age. Approaching 60, he was older than most homeless
people at the shelter. Angus realized that Hank was facing medical issues as well as great difficulty in finding a
job because of employers’ tendency to discount older individuals’ ability to contribute. Challenges and
discrimination on the basis of age take many forms and were clearly elements in Hank’s life.

140

Planning

A third component of the change process is planning, or figuring out what to do—purposeful action—given
the situation. In many instances, a written case plan, a contract designed collaboratively by the social worker
and the client, is developed. Case plans comprise short- and long-term goals and corresponding strategies for
achieving them. When appropriate, family members, friends, and the neighborhood can be included in the
planning process and be part of the plan.

Planning documents often include a table delineating each strategy and assigning the name of the person
responsible for that strategy, along with an estimated date for its completion. The signatures of both the client
and the social worker formalize their collaboration and establish accountability for the agreed-on actions.

Contained within the plan are strategies and goals that directly impact the client—in other words, micro-level
goals. One of Hank’s individual goals was to secure a permanent residence close to public transportation.
Hank also knew from his shelter experience that the city had a well-documented need for low-income
housing in safe neighborhoods. He planned to attend city council meetings, along with others interested in
housing issues, to better understand the bureaucracy associated with public housing and to network with those
involved in the city’s housing development, with a focus on housing options for older people.

Time to Think 3.6

Consider a time when you had to make a major decision, such as where to attend college. Did you ask anyone to help you with the
decision-making process? If so, who did you ask, and why did you select that person? Was an empathic approach a consideration? Is
it hard for you to ask for help? Why might some people have a problem seeking help?

When Angus and Hank worked on this plan of action, Angus reinforced Hank’s decision making and
supported his right to select strategies that directed his life toward his personal goals. In the planning process,
Hank was seen as the expert and Angus as the facilitator.

141

Implementation

A typical next step in the change process is implementation, the actual performance of the activities outlined
in the plan for reaching stated goals. The social worker and client monitor the plan during implementation to
make sure their strategies are being followed and to make adjustments as deemed necessary. This is yet
another meaningful way to connect the social worker and the client. Keep in mind that the actions called for
in the plan reflect the client’s situation and view of reality in the context of his or her strengths and specified
problems.

For example, during this phase, Angus highlighted Hank’s success and considered ways to improve any
strategies that seemed inadequate. Hank found a place to live, which both Angus and Hank celebrated. Hank
also attended a city council meeting. However, when Hank realized that attending one meeting would not
likely improve the city’s overall housing situation, he became discouraged. Angus suggested that Hank go to
another meeting and introduce himself to attendees who might share his concerns. Angus’s words of support
and emphasis on Hank’s success were critical to Hank at this stage. Maintaining motivation was crucial for
implementing Hank’s plan, as was affirmation of success in progress toward his goals.

Current Trends

142

Social Workers and Political Action
The National Association of Social Work has a Public Policy Department that advocates for the association to members of Congress
and regulatory agencies that hold the authority to influence social welfare policy. Annually, NASW develops a Policy Agenda, which
asserts the association’s advocacy priorities for the legislative cycle. NASW’s Policy Agenda is consistent with the NASW policies in
Social Work Speaks, a comprehensive policy statement that is developed by members of the association at delegate assembly (see
www.socialworkers.org/advocacy/default.asp).

1. How does a network of professional social workers willing to contact their members of Congress help social work clients and
their communities?

2. Given the current political climate, what items do you think social workers should have on their Policy Agenda and why?
3. Explain the overlap between the political arena and the social work profession.
4. How does social work’s Code of Ethics interface with issues listed on NASW’s Policy Agenda, especially in the realm of access

to needed services and resources?

Spotlight On Advocacy

143

Health Care: A Question of Ethics
Social work practice often involves ethical dilemmas involving individuals and small groups. Dilemmas can also be seen in the
nation’s political system. For example, how should the United States provide health care to citizens given the competing opinions
associated with shrinking or expanding the federal government, reducing the federal budget, preserving states’ rights, responding to
lobbyists, supporting the American Medical Association, endorsing citizen participation, and cooperating with the pharmaceutical
industry? The quandary is how to address this complex issue in an ethical manner that moves beyond the notion of “winners and
losers” to a position of social justice, where people are able to access and receive needed medical services.

1. Given what you know about social work values and ethics, what advocacy position do you think the profession should take in
response to health care coverage for uninsured citizens?

2. Examine the nation’s current heath policies at www.whitehouse.gov. What ethical issues surface when you consider program
criteria, coverage, and costs?

3. Explore the website of the Kaiser Commission on Health Care (kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-
population/), an advocacy health care organization, and list at least three strategies this organization supports to address the
health care for the uninsured. Would you add any strategies to the list? If so, what are they?

144

Evaluation

Evaluation, an often identified final step in the change process, is in reality integral throughout. The purpose
of evaluation is to monitor implementation of the plan and ensure that designated activities are effectively
accomplishing intended goals. Evaluation marks progress, provides insight into the success of initiatives, and
informs future plans—including aftercare activities.

Evaluation gives meaning to the collaboration between the social worker and the client. It allows for an
examination of what was accomplished and how change occurred for the client and the environment. It is an
element that accentuates accountability between the social worker and the client, ensuring that both are
working to accomplish the agreed-on goals in accordance with the negotiated timelines. In the end, evaluation
reflects the quality of the plan and highlights what has and has not been accomplished.

Time to Think 3.7

Given your strengths and interests, which components of the change process would you be most comfortable initiating? What would
it take for you to become more comfortable with the other components?

145

Advocates For Change

Advocacy is integral to all social work practice, including generalist practice. It is rooted in an ethical
obligation to address and diminish human suffering, discrimination, and oppression. The professional
responsibility for advocacy provides social workers with a foundation and mandate to support political, reform,
and action agendas to address issues of economic and social justice and rights. The professional commitment
to large-scale change addressing social problems encourages advocacy as a means of improving an
organization, community, and society through cause advocacy.

At the same time, generalist social workers perform micro-oriented practice with individuals and families;
much of their time is spent in case advocacy. By being cognizant of and envisioning a preferred state of affairs
for clients—whether a permanent address for a homeless person, health care for a person with diabetes, or
child care for a working mother—generalist social workers use their knowledge to develop helping strategies
both for addressing immediate needs of clients and for creating larger-scale change.

The helping relationship between Hank and Angus exemplifies how the generalist social worker needs to be
attentive to micro, mezzo, and macro levels of change. Social workers advocate not only to assist a particular
client with obtaining specific services but also to create opportunities for others facing similar problems and
issues.

The underlying process of advocacy does not depend on issue or client system level (e.g., individual, family,
group, organization, community, or society) but, rather, is guided by the idea that social work is an
empowering profession. In this context, advocacy is the active support of client involvement and impact
concerning decisions related to an idea, need, or cause. Both case and cause advocacy are expressed through
strategies and methods that influence the opinions and decisions of people and organizations. Influence can be
brought to bear through the following activities (UNICEF, 2010):

Defining the problem: Examining the situation in detail to understand the underlying causes of the
problem
Recognizing the strengths: Assessing potential assets and resources within individuals, groups, and
organizations
Raising awareness: Educating the individual or the public by presenting evidence-based and solution-
oriented messages
Developing partnerships: Generating organizational support and momentum behind the issue being
addressed
Lobbying and negotiating: Discussing the issues and desired changes with decision makers and people of
power in the situation
Generating and consuming research: Examining the underlying causes of and solutions to a problem
Facilitating social mobilization: Engaging allies and partners at multiple levels
Planning events: Bringing together a variety of people to highlight the issue or concern and work toward
solutions

146

Summary

Social workers address problems and issues in a variety of settings and at a variety of client levels—individuals, families, groups,
organizations, and communities. Hence, generalist social workers need to possess a breadth of information and a broad array of
skills. Their practice is based on a large body of knowledge, competencies, and behaviors, which are merely touched on in this
chapter.

The change process used by the generalist practitioner is predicated on problem solving as well as a strengths-based perspective that
requires social workers to assume a wide range of practice roles. Each component of the change process is based on professional
ethics, collaboration and a sound working relationship between client and social worker. Critical thinking, the careful examination of
facts and opinions (especially prior to formulating conclusions), is another key element of the change process. Similarly, reflective
thought, acquired through interaction with clients and other knowledgeable parties, is a critical component for effective practice.

147

Top 10 Key Concepts

client system
code of ethics
direct practice
ecological perspective
empowerment theory
evidence-based practice
generalist social work practice
person-in-environment perspective
strengths perspective
systems theory

148

Discussion Questions
1. Review the possible roles of generalist social workers, and discuss the role(s) that best match your interests and skills.
2. Consider the change process and discuss how you would engage a client. What do the terms empathy and rapport mean to you?

Provide an example of a person with whom you have established rapport. When and how have you shown empathy toward
someone?

3. Which component of the change process—engagement, assessment, planning, implementation, or evaluation—is most significant
to the process, in your opinion? Why?

4. A case involving a social worker named Angus and a client named Hank was used as an example in the section on the change
process. What were some of the strengths Angus displayed when working with Hank? What additional skills do you think would
help Angus facilitate the change process for his clients?

149

Exercises
1. Investigate the baccalaureate social worker licensing procedures for your state. What do the licensure requirements tell you about

the roles of generalist social workers?
2. Interview a generalist social worker to better understand how he or she applies generic skills to individual problems. Write a brief

description of your findings.
3. Volunteer at a community agency such as a homeless shelter, food pantry, or used clothing store. Analyze your experience as a

volunteer in terms of the information you read in this chapter. What information from this chapter was most relevant to your
volunteer experience?

4. Research a national or international advocacy group, such as Amnesty International or Greenpeace. Describe how the
organization links individual concerns to national and global causes.

Online Resources

Association of Baccalaureate Program Directors (www.bpdonline.org): Lists baccalaureate program guidelines
Social Work Policy Institute (www.socialworkpolicy.org): The Social Work Policy Institute describes evidence-based
practice and provides information on resources.
National Welfare Rights Network (www.welfarerights.org.au): Describes a grassroots organization in relation to advocacy by
poor people on behalf of themselves and others
Phi Alpha National Honor Society (www.phialpha.org): Provides details on membership and activities in this society for
baccalaureate social work students
Women’s Empowerment Principles (www.weprinciples.org): Guidelines from the United Nations define the roles of women
in the context of redistributing power and privilege.

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

150

Chapter 4: Advocacy in Social Work

Source: Pacific Press/Contributor/Getty Images

151

Learning Objectives
After reading this chapter, you should be able to

1. Differentiate case advocacy and cause advocacy.
2. Summarize the ethical issues involved in advocacy.
3. Explain how advocacy is a signature aspect of social work practice.
4. Identify costs and benefits associated with advocacy.
5. Describe a cycle of advocacy.
6. List and describe four tenets of the dynamic advocacy model.

Nancy Advocates to Professionalize Social Work in Her State

Nancy is a BSW-level social worker residing in a state that recognizes and provides licensure only for MSW-level clinical social
workers who have passed a national examination and completed at least 2 years of supervised clinical experience. The license is what
allows clinical social workers to enter private practice with individuals and families, obtain reimbursement through insurance
companies and other third parties, and tap into public funding sources. In contrast, BSW and nonclinical MSW social workers have
been limited to obtaining state certifications in social work. These certifications lack credibility with potential clients and funding
sources.

In Nancy’s state, human service organizations rarely require proof of certification or of a degree in social work for employment as a
social worker in nonclinical settings. So by law, just about anyone with at least a bachelor’s degree can choose to be called a social
worker. People who have majored in psychology, sociology, criminal justice, history, and English routinely obtain employment in
human service and mental health agencies in her state. They often refer to themselves as social workers, care managers, caseworkers,
and intervention specialists. As a result, the general public believes that the term social worker can be applied to nearly anyone doing
good for others.

Nancy worked hard for her BSW degree and wonders how nonprofessionals can effectively do the work without the training she has
received. It seems to her that the potential for doing harm is high.

The important point here is that Nancy is thinking and acting as an advocate. To ensure that clients receive quality services from
competent social workers, Nancy works with her National Association of Social Workers state chapter and local social work
educators to promote state legislation that will establish licensure and title protection for all social workers. As their recommended
changes in state laws are considered, social workers and some client groups have also been talking with administrators of social work
agencies about how important it is to require that every “social worker” in a human service position have a social work degree and be
appropriately educated.

Social workers can act as advocates for their clients by promoting legislation that has a positive effect on the
community.

Source: iStock Photo / gremlin

The element of social work that greatly distinguishes it from other helping professions is advocacy. Social

152

workers are unique in being oriented to and knowledgeable about advocacy—engaging in purposeful actions
that will help people advance their rights, opportunities, causes, and human dignity—a hallmark of social
work. Social workers believe in empowerment through advocacy to help improve people’s lives, family
dynamics, group processes, organizational functioning, community-based ventures and services, and policy-
oriented decisions and guidelines.

Grounded in the Code of Ethics of the NASW (2018), one of social work’s central principles is to promote
social justice through work with socially and economically vulnerable groups. Populations at risk include the
economically disadvantaged, members of the LBGQT community, women, older adults, children, racial and
ethnic minorities, and people with mental or physical challenges. Contemporary social justice issues include
unemployment, underemployment, medical insurance, technological access to information, and the
elimination of discrimination. Social workers seek equality of rights and opportunities for all people in a
number of realms. And, a major way of advancing social work’s social justice agenda is through advocacy.

Advocacy can involve one case (many times an individual or family) requiring some kind of change, which is
known as case advocacy. It may also take the form of a larger structural or systematic effort to change policies,
common practices, procedures, and laws to advance social justice for a larger segment of society, which is
known as cause advocacy. Cause advocacy necessitates social workers to be knowledgeable about social action
and ways to create social change. Social workers engage in many types of cause advocacy, such as legal
advocacy, legislative advocacy, self-advocacy, and system advocacy.

The goals of case advocacy are often to meet individuals’ absolute needs, or the basic goods and services that
support human survival in the short term (water, food, shelter, sanitation, medical care). The goals of cause
advocacy involve causes that impact a group of people and, like case advocacy, can encompass relative needs,
which are the goods and services that promote human dignity and well-being over the long term: meaningful
employment, equal status before the law, social justice, quality education, and equal opportunity.

153

The Need For Professional Advocates

Many people are unable to provide adequately for themselves at one point or another; some people experience
a lifetime of challenges from which they struggle to escape. The personal reasons vary, from physical or mental
barriers to lack of proper socialization and education to lower social status through birth, custom, or
misfortune. In addition, societal factors such as a lack of public resources and service, unsupportive political
will, and entrenched systems of privilege and oppression impact and constrain the ability of people to move
forward. Many people often struggle with the basics—food, water, shelter, health care—and human dignity.

Societies across the world have developed systems to create opportunities for people to rise above unfortunate
circumstances. In Chapter 2, you read about the historical response to need, the development of social work as
a profession, and the emergence of a unique system of social services in the United States. Social programs
and services have helped millions of people live more fulfilling, healthier, and productive lives.

Often, however, social services are unknown or unavailable to those in need. It is difficult for people without
resources to learn about sources of help and ways to challenge barriers suppressing human growth and
development. Social workers have long worked to connect individuals, families, and communities with the
available services in an effort to provide people with an opportunity to participate fully in society. In the
process, they have become advocates, championing individuals, groups, and communities in their search for
needed services. But social workers soon realized that when services were unavailable to meet serious needs
within communities, they would also need to be advocates for policy and program changes with larger systems
—organizations, communities, and society.

Both case and cause advocacy require knowledge, determination, and effort, many times with people
consumed with just trying to survive. Social workers, on the other hand, have committed themselves to
helping the needy as their life work. They have acquired education and training to develop knowledge and
skills to use client strengths to challenge barriers. Social workers think in terms of a responsibility both to
improve conditions for clients and to advance opportunities for other people facing similar struggles and
problems.

Current Trends

154

Social Change Through Boycotts
One way those without much individual power can effect change is to band together to refuse to buy a product, use a service, listen
to a radio station, or watch a television program—in other words, to conduct a boycott. During the 1950s, civil rights leaders such as
the Rev. T. J. Jemison and Dr. Martin Luther King organized bus boycotts and alternative car pools in the cause of abolishing rules
forcing African American riders to the backs of buses. In 1977, a boycott began in the United States, and eventually expanded into
Europe, protesting Nestlé’s promotion of breast milk substitutes in less economically developed countries. A boycott of U.S. firms
investing in South Africa, which included protests on American college campuses, contributed to the end of official apartheid in
South Africa in the 1990s. These are just a few of the historic examples of effective boycotts.

In today’s electronic world, groups such as Ethical Consumer enlist people in social change. Ethical Consumer publishes lists of
companies that it believes should be boycotted on the basis of political oppression, animal abuse, tax avoidance, environmental
degradation, supply chain issues, abuse of human rights, and exploitation of workers. When organized and conducted successfully,
boycotts such as these bring publicity to issues and serve as powerful forums for advocating change.

In the political realm, beginning with the election of President Trump in 2016, anti-Trump protesters began boycotting Donald
Trump products (e.g., hotels, real estate, golf courses, and resorts). And, following the endorsement of the clothing line of the
President’s daughter, Ivanka Trump, by Counselor to the President Kellyanne Conway, anti-Trump groups soon organized to
boycott Ivanka’s clothing as well as the stores selling her products. Would you participate in a political boycott? If so, for what
political purpose and end?

Advocacy can occur via organized demonstrations to challenge people in power and effect change.

Source: Spencer Platt / Staff / Getty Images

155

Power and Social Inequality

Implicit in this discussion of why professional advocates—that is, social workers—are needed is the idea of
social inequality. Some people have more—access to society’s benefits and resources, status, wealth, power—
and some have less. Some inequality is part of the human condition. However, those at the top may use their
advantages to organize society to suit their needs. Often they do so to the clear detriment of those below them
on the social scale. Social workers are educated to understand these inequities and their effect on clients and
social systems. They are also educated to combat social inequality at all levels and in various areas of practice,
as you will learn in later chapters.

During the past several decades, social workers have embraced the concept of empowerment as a key feature
of practice. In the context of advocacy, empowerment refers to clients’ ability to influence decisions made
about themselves, determine the best outcomes for themselves, and making life-changing decisions
themselves. They influence both the services they receive and the development of policies, programs, and
legislation that affect the services they and others receive. Social workers are key players and leaders, but their
role is to facilitate, work with, and support clients in their efforts to advance their own well-being and
promote change.

Power is a factor in human services in another way. When social workers defend or represent others to secure
social justice, they are challenging the people and special interest groups in power to exert their authority to
assist and benefit those who are less powerful. When this type of advocacy is successful, the will and energy of
clients and social workers, as well as the other advocates for change, yield desirable, measurable outcomes that
produce additional opportunities, rights, and freedoms for clients.

Consider how Nancy, the social worker in our opening vignette, decides to approach those in power over
licensing requirements for social workers. She realizes that her campaign may be an affront to certain groups.
The likely opponents are individuals working in the field who do not have social work degrees, and budget-
minded legislators and administrators. Antilicensure elements will question whether licensed social workers
can do a better job than those who are already doing it without licensure. They will ask for evidence but may
still dispute findings indicating that the quality of services is enhanced through the employment of
professionally educated and degreed social workers.

Social Work in Action

156

March 2017 Effort to Repeal and Replace the Patient Protection and
Affordability Care Act (ACA)
Social workers across the nation united with various special interest groups and factions to lobby members of the U.S. House of
Representatives and Senate to thwart President Trump and Republican efforts to repeal and replace the Affordable Care Act
(ACA). Passage of ACA repeal and replace legislation held promise for eliminating health care insurance for millions of low-income
and older adults across the United States.

So Nancy devises a strategy for challenging the status quo that involves empowering clients and enlisting the
support of service groups. She has heard many disturbing stories of clients’ receiving inappropriate or inferior
services from nonprofessionals, and she believes those stories will sway decision makers. In addition, Nancy
believes that clients’ voices will resonate because each client brings unique passions and strengths for
influencing change. Some clients are poised to step forward in the licensure debate and want to educate others
to the ill effects of nonprofessional intervention. They, and the groups they form, will play a significant role in
reaching out to administrators, leaders, and legislators in the state.

Supporters of the Affordable Care Act participate in a “Save Obamacare” rally in Los Angeles, California on
March 23, 2017.

Source: NurPhoto / Contributor / Getty Images

157

The Ethics of Advocacy

Underlying their involvement in advocacy (and all forms of social work intervention) is the professional call
for social workers to engage in ethical behavior in practice. The Code of Ethics of the National Association of
Social Workers (NASW) states that each social worker has an obligation to “advocate for living conditions
conducive to the fulfillment of basic human needs” (NASW, 2018, Sec. 6.01). Social workers are also
instructed in the Code of Ethics to approach, initiate, assist, educate, and organize clients for participation in
advocacy. The responsibility for advocacy is also spelled out in the International Federation of Social Workers’
(2004) statement of principles for ethical social work practice.

Advocacy is thus often viewed by social workers as a professional mandate and mark of competency. Nancy’s
call to license social workers in her state is a function of her ethical obligation to promote the well-being of
her clients via competent practice. However, social workers exert care in advocacy not to impose their own
values and interests. Social workers hold positions of power in helping relationships, which can influence
client perceptions and actions. Ethical advocacy, whether efforts to advance competent practice or any number
of issues or causes (e.g., safe and affordable housing, child welfare, affordable health care), is foremost
centered on client needs and desires.

Client Self-Determination

Advocacy in social work practice is predicated on the principle of client self-determination, which dictates
that consumers of services make decisions and choices based on their will and value orientations. Because
there is a power differential between social workers and clients, it is important for advocacy to occur in a
fashion that encourages and does not distract from or violate the client’s right to self-determination.

With advocacy, the social worker is by definition taking up the cause of others. To promote client self-
determination, social workers are attentive to setting aside their personal values, and they attempt to examine
an issue or cause from the perspective(s) and voice(s) of the client. Placing oneself in the position of the client
is difficult, as it necessitates learning from the client and the ability to successfully work through unequal
power dynamics in the social worker and client relationship.

Self-Interest and Advocacy

It is important for social workers to know the differences between self-interest (defined as a focus on one’s
own benefit), case advocacy, and cause advocacy. Social workers should enter the profession to help other
people, especially members of vulnerable population groups (e.g., people who experience prejudice based on
gender, sexual orientation, economic status, race, or ethnicity), and not themselves. Social workers are client
centered.

To understand the difference between self-interest, case advocacy, and cause advocacy, think about what
college students might do when they are unhappy about a grade they received on a group assignment. One
student might argue that the instructor should have graded his or her contribution higher because the other

158

members of the group did not do as much work to complete an assignment. Another student might tell the
instructor that the group deserves a higher grade. A third student might point out some weaknesses in the
assignment or the grading rubric and that all students in the course should be given a higher grade. Which of
these challenges constitute advocacy? Are any of them an example of case advocacy or cause advocacy? Which
are based primarily on self-interest and personal gain?

As you may already sense, the concept of advocacy in social work is multidimensional and differs from the
idea of advocating for one’s own personal and private needs and rights. Case advocacy is important for helping
specific individuals, families, groups, organizations, and communities address needs and concerns. Cause
advocacy focuses on social change and enabling larger groups of people to improve their social and economic
situation.

Time to Think 4.1

What motivates you to consider social work as a profession? Have you experienced a loss, difficult living circumstances, a traumatic
event, or a violation of personal rights? If so, are you motivated to consider social work out of self-interest or out of a concern that
others benefit from your experience?

Social workers strive for objectivity in assisting clients. Could you be objective if your advocacy involved a significant event or factor
in your life?

Individual Benefit Versus Community Benefit

In the United States, people often conceptualize needs in individualistic ways—what can be done for me or
this person—as opposed to contextualizing them in group or community welfare and large-scale change.
Although individual-level advocacy can produce needed benefits for the person, it frequently does not prompt
community or institutional reform. One way to think about the difference between advocacy and self-gain is
to determine whether the individual or a group of people is the primary beneficiary of the change process. The
individual reigns supreme perspective equates individual gain and interest with the common good and is
useful for seeing how case advocacy has limitations (McNutt, 1997). For example, advocating with a client to
receive food assistance from an organization can be critical for addressing a person’s immediate needs but may
have little impact for subsequent people experiencing similar circumstances.

It is important to question whether promoting solely one’s own rights in a single case constitutes effective
advocacy and use of time. Many social workers argue that advocacy efforts should move beyond individualism
and focus on efforts to promote social justice or improve social conditions or circumstances affecting other
individuals or a group, community, or society. The attitude of placing self-interest in a context of promoting
policies and practices for the common good aligns with the community reigns supreme perspective (McNutt,
1997). For example, taking the broader view of advocating with clients to promote just policies for receiving
food assistance from organizations in a community can yield immediate assistance to a person in need and
holds promise for benefiting other people as well.

Although social workers are encouraged to focus on others, the motivation and ability to stand up for one’s
own rights can be a desirable personal attribute for social workers. How can people who are unable to muster

159

the energy and passion to help themselves effectively promote fairness and social or economic justice for

others? There is something to be said for people being willing to participate actively in a case or a cause rather
than just look on passively. If you are seriously considering entry into the social work profession, contemplate
your abilities and potential to “stand up” and actively work with others to address clients’ needs and address
important issues and causes.

Pathways to Community Benefit

To promote social change, social workers advocate for pathways that will give groups of people access to
resources, rights, and opportunities, and allow them to improve their life circumstances. The role of the social
worker, therefore, involves “building avenues for clients to access power resources within themselves, their
families, and their contexts . . . creating opportunities for significant participation in community and thereby
freeing clients to experience themselves differently and act in new ways” (O’Melia, 2002, p. 3).

Rallies and protests are one way clients can be empowered to participate in their community.

Source: Anadolu Agency / Contributor / Getty Images

Using the example of requesting a grade change, consider the possibility that a number of students were
adversely affected as a result of an unfair grading practice. The correction of a single grade would not facilitate
grade changes for others also affected by that unfair or unjust grading practice. Possibly, if the course had large
enrollments, the grading of essays was relegated to teaching assistants (TAs). If so, did the TAs receive proper
training and clear instructions and grading rubrics to facilitate reliable and valid grading practices? One might
question if scoring of essay answers varied appreciably among TAs. Or was there any political pressure from
the professor, department, or university administration to keep grades low to combat grade inflation? Were
environmental factors or conditions, such as assigning the group work during local fires and power outages,
involved?

Identifying and asking important questions opens up pathways for possible resolution of the grading problem.
For example, when prompted, the professor might review the grading practices of the TAs for consistency and
fairness, and consider any necessary grade changes. The professor could also examine best practices of other

160

professors and incorporate their perspectives concerning grading into a training program for TAs, to minimize
bias and error. Or the professor might have been unaware of the impact of local fires on the group assignment.
In the process of examining grading policies, the professor might have identified discriminatory differences
among grades from the TAs based on gender, race, or age of the students. Once again, advocacy involves a
broad and dynamic assessment and understanding of political, economic, social, and environmental factors
that can influence decision making affecting a number of people.

161

Human Aspects of Helping

Social workers often work with clients and constituents who are under stress and feel desperate and powerless.
When considering advocacy as a means of creating change, it is essential to keep the human aspect of helping
in mind. People are susceptible to pain and permanent damage and can perish when critical needs go unmet.
All people should be treated as human beings with dignity, not as problems, objects, or cases (Reynolds,
1951).

The human nature of advocacy involves both emotional and rational aspects. Passion to confront issues can be
a powerful asset in promoting change, but it can also blur many of the realities associated with a situation or
issue. Hence, objectivity is an important aspect of advocacy and a quality that social workers can contribute to
the process. Social workers need to be able to put clients’ values and interests first while providing professional
insight concerning the realities, good and bad, associated with proposed change.

Time to Think 4.2

As a social worker, you would want to see, appreciate, and respect the unique qualities of each person and group you encounter. You
might think of social interaction as one big museum for discovering the commonalities and differences among people. In the context
of advocacy, are you or could you be capable of viewing and appreciating the strengths and vulnerabilities of a variety of people—
including those who think and behave quite differently than you do?

162

Social Workers and Social Change

Social work pioneers became aware of the need for cause advocacy when they recognized that addressing
clients’ immediate needs from a charitable perspective held little promise for creating substantial and
sustainable change in people’s lives. Temporary and survival-oriented efforts were analogous to using adhesive
bandages for large, contagious sores. Although it was important to address individuals’ needs for shelter, food,
water, and sanitation, and to alleviate other forms of human suffering, it became apparent that collective and
political action was also necessary. Confronting mechanisms of social control (such as policies, practices, and
laws) and people in positions of power was necessary to promote human well-being and social justice.

Dorothy Height, Florence Kelley, and Whitney Young are important historical civil rights leaders who
dedicated their lives to social reform and the expansion of social welfare and policies in the United States. For
example, Dorothy Height was an African American woman admitted to Barnard College in 1929 but denied
entrance to the school as a result of a racial quota—a practice Barnard College later discontinued and officially
denounced. She earned her undergraduate degree (1932) and master’s degree in educational psychology
(1933) from New York University, later completing postgraduate education at Columbia University and the
New York School of Social Work (now known as the Columbia University School of Social Work). Dorothy
began her career as a caseworker with the New York City welfare department and was a prominent leader
during the civil rights movement of the 1960s. In addition to serving in a considerable number of national
leadership positions, Dorothy served for four decades (1957–1997) as the president of the National Council of
Negro Women. She is remembered nationally for promoting understanding of and rights for African
American women, and she was honored with the Presidential Medal of Freedom in 1994 and Congressional
Gold Medal in 2004.

Dorothy Height was one of the first civil rights leaders to conceptualize and advocate for social justice and
equality for women and African Americans in a unified, holistic fashion. She was a proponent of social
programs benefiting African American females, black families, and strong, healthy community life. In the
1980s, Dorothy was known and honored for promoting and helping to sponsor “black family reunions,”
designed to celebrate the history and traditions of African Americans. Unfortunately, despite her many
accomplishments, Dorothy Height’s tireless work has often received far less attention and accolades than her
male civil rights counterparts.

163

Cause and Function

The idea that cause advocacy is a key component of social work got a significant boost from a 1937 book,
Social Work as Cause and Function, by social work educator Porter R. Lee. This was a question he addressed in
the book:

Are social workers merely part of a function, helping people adapt to the environment into which
they are thrust, or do social workers intend to act in promotion of a cause, altering the social context
to allow for higher-level changes in social problems? (Stotzer & Alvarez, 2009, p. 324)

Lee viewed social workers as professionals with responsibilities involving community practice, social action,
and leadership. His vision of social work expertise went beyond helping skills and focused specifically on the
ability to create social change and lead social movements. He considered social workers to be uniquely
equipped to advance the interests of those with absolute and relative needs. As experts in social action and as
professionals, they could make social action more effective than could those taking the “emotional role” of a
person not trained in social work (Stotzer & Alvarez, 2009, p. 325).

Dorothy Height was a prominent advocate for the rights of African Americans.

Source: © Adrian Hood/CreativeCommons

Lee’s writings shaped the social work profession in a number of ways:

Advancing the value of professional education and training in social work
Moving the identity of social workers away from simple helper toward agent for systemic change
Emphasizing objectivity (as opposed to emotion) in providing services and promoting social change

Lee’s thoughts from the 1930s concerning the role of social workers in social action carry weight today.
Whether the issue is inadequate health care; a faltering economy; oppression of women; challenges for older
adults; oppression of racial/ethnic groups and people from the lesbian, gay, bisexual, and transgender

164

community; or the plight of veterans, social workers are challenged to be resolute in their commitment to
partner with vulnerable and disenfranchised groups.

165

Responses to Hard Times

A notable turning point for social welfare and cause advocacy in U.S. history occurred during the Great
Depression of the 1930s, when social and economic conditions challenged prevailing assumptions about
public assistance and the belief in individual responsibility. For the first time in their lives, many Americans
were confronted with the reality that social and economic forces beyond one’s control can have harsh
consequences for individuals and families. Threats to average Americans’ absolute needs produced a pervasive
sense of desperation and helplessness. Many Americans began to see the wisdom of collective action to inform
leaders about their common plight and to argue for social and economic relief programs.

Social and economic turmoil often serve as the stimulus for change in communities or societies. Change was
also in the air from the mid-1960s to the late 1970s. Many people protested the nation’s involvement in the
Vietnam War, riots occurred in urban ghettos, civil rights protests abounded, and women sought relief from
oppressive policies, practices, and laws.

Many social workers supported President Lyndon B. Johnson’s 1964 declaration of a War on Poverty and
advocated for the creation of programs and services to improve Americans’ general welfare. “These initiatives
included Volunteers in Service to American (VISTA), a domestic version of the Peace Corps; the Job Corps,
an employment training program for school dropouts; and Head Start, a preschool educational program”
(Long, Tice, & Morrison, 2006, p. 12).

During the politically conservative 1980s, social workers exposed the consequences of President Ronald
Reagan’s attack on social welfare programs for the poor and the windfall benefits for the rich of Reaganomics’
tax reforms (Piven & Cloward, 1982). Social workers also brought new issues—problems of drug use,
homelessness, and sexually transmitted diseases, among others—to the attention of the public and decision
makers.

Participants, some carrying American flags, marching in the civil rights march from Selma to Montgomery,
Alabama in 1965.

Source: Library of Congress, Prints and Photographs Divison, LC-DIG-ppmsca-08102

166

Cause Advocacy Today

As a result of the many progressive policies and initiatives supported and advanced by former President Barack
Obama, many social workers became inspired about the impact of advocacy for creating social change. Social
workers actively partnered with client groups to advocate for federal funding to support those suffering from a
failing economy and to identify and advance the rights of a variety of vulnerable populations. These are some
of the issues that social workers actively advanced:

Health care reform (including national health insurance and parity laws to cover mental health services)
Lesbian, gay, bisexual, and transgender rights
Services for veterans returning from the wars in Iraq and Afghanistan
Fair and just treatment of all immigrants in the United States, including those who are undocumented
Affordable housing
Independence and dignity for older adults
Fair treatment of those infected with HIV/AIDS
Quality delivery of social services based on practice-informed research and research-informed practice
Substance use and mental health programs
Environmental and climate change

With the 2016 election of President Trump and Republican majorities in the U.S. House of Representatives
and Senate, the national political climate with respect to advocacy shifted for many social workers toward
protection and retention of policy and program advancements with the issues listed above. For example, early
in his presidency, Donald Trump proposed federal budget reductions drastically reducing funding and support
for programs related to health and human services, housing, environmental protection, and education.
Reductions in federal funding serve to undermine advancements in areas noted above and necessitate advocacy
efforts for funding and support of initiatives at the state and local levels.

The majority of social workers see cause advocacy as part of their professional identity. For example, in one
survey of social workers, “more than half” agreed that political action is relevant to their jobs and that they are
obliged to “stay informed, educate others, and advocate for constructive policies” (Rome, 2010, p. 115).
Additionally, 78% reported being educationally prepared for political participation and civic engagement
(Rome, 2010, pp. 116–117).

167

The Cost of Advocacy

Although advocacy is a core function in social work practice, it should not be undertaken without an
understanding of the cost of advocacy—all the real, intangible, and unintended ways that undertaking
advocacy can deplete resources and potentially work against the cause. For instance, bad publicity, loss of
social capital (e.g., pushback and alienation from allies), and false hope can be just as detrimental as the loss of
funds and other resources (e.g., the time of advocates) dedicated to the cause. Often the costs of advocacy are
considerable (McNutt, 2011). However, comprehensive cost–benefit analyses of advocacy efforts take into
account the costs, the prospects of attaining the goal, and the extent of the good to be derived from advocacy.

Time to Think 4.3

Have you participated in an advocacy event or movement? How comfortable were you, on a social–emotional level, with that
involvement?

Social workers network and align themselves with diverse types of people to advocate for social change. Would you be able and
willing to advocate for rights and opportunities for people whose gender identity, social class, race or ethnicity, age, physical or
mental ability, or sexual orientation is different from yours? If not, why? Do you think you might change your attitude to become a
social worker?

Assessment of the costs associated with any advocacy initiative, whether case or cause oriented, is likely to be
multidimensional and can be time-consuming. Each agency or organization involved may incur expenses. In
addition, the cost of advocacy includes determining the value of each person’s time to engage in research,
analyze and draft policies, attend meetings, develop media strategies, lobby, organize communities, and
campaign. Communication itself—with constituent groups, leaders, politicians, and decision makers—
requires a great deal of time, as well as expertise in various modes of communication, from the telephone and
print media to text messages, websites, e-mails, blogs, wikis, and social networking sites.

Potential financial cost is not always an argument for abandoning or retreating from advocacy. A long-
standing adage in business is, “You need to spend money to make money.” For advocacy, this adage can be
altered to, “You need to commit resources to effectively create change.” The key in social work is to be
mindful, intentional, and informed about the types of costs associated with planned changed.

Of course, on the other side of the ledger, advocacy has benefits. To evaluate the benefits of advocacy, those
involved need to clearly define the criteria for success and ongoing means for evaluating whether advocacy
outcomes are being reached. Once again, professional social workers can lend their expertise to the evaluation
of the effectiveness of interventions and programs.

For example, Nancy has begun to consider benchmarks for success in reforming social work licensure
requirements in her state. From the outset, she and the client groups and advocacy partners with whom she is
working will need to identify the goals and benefits of licensure reform, consider the associated costs, and
develop mechanisms to monitor their progress toward achieving it.

168

169

A Model For Dynamic Advocacy

Chapter 3 introduces a model for generalist social work practice, along with the theoretical foundations for
that practice. This chapter introduces a similar model for advocacy, the advocacy practice and policy model
(APPM). Exhibit 4.1 on page 67 depicts the theoretical foundations of the APPM:

Systems theory: Although much of social work involves practice with individuals and families, advocacy
takes place with systems of all sizes—including groups, organizations, communities, and societies—as
both clients and targets for change. A community could be the client for case advocacy, where a social
worker advocates for a particular community seeking funding for a new social work agency. An example
of cause advocacy is when a social worker partners with organizations to change a county or state policy
or law restricting their ability to provide needed services (e.g., family planning and contraception
education).
Empowerment theory: Both case and cause advocacy involve social workers’ building relationships with
clients of various system sizes to participate in and impact decision-making processes. Empowerment-
based case advocacy promotes the voice, perception, and ability of clients to influence a particular issue
of importance to the client. Similarly, empowerment-based cause advocacy emphasizes the perspectives
and abilities of clients to advance issues affecting them as well as others.
Strengths perspective: In advocacy, it is important that social workers give appropriate attention to both
the problems confronting client issues and the various strengths available to create needed change.
Whether case or cause advocacy, clients of all sizes (e.g., individuals, families, groups, organizations,
communities, and societies) bring to the advocacy process a variety of strengths, including resources,
abilities, important relationships, knowledge, skills, insight, perspective, energy, and passion. For
example, you may think that economically poor clients have limited strengths to advocate for change; yet
their voices, knowledge, and perspectives are unique, and the very emotion and passion they bring to any
situation can be especially convincing, powerful, and impactful in advocacy.
Ecological perspective: When advocating for change, assessment of the total environment, not just people
and social systems, is vital. Physical and natural resources such as technology, buildings, transportation,
water, soil, air, plants, and animals can be assets as well as challenges for case and cause advocacy. For
example, consider the value of phone and Internet access for both case and cause advocacy. The poor are
especially challenged in advocating for themselves and others without technological means (e.g., public
access to the Internet and e-mail and to low-cost public transportation) to network and communicate
with others to create change.

Spotlight On Advocacy

170

171

In-Home Services for Older Adults
Joan is a social worker employed by her county’s council on aging in a special extended stay program (ESP). Her primary
responsibilities are to identify services and programs to allow seniors to reside in their homes. Several years ago, county officials and
local social service leaders listened to the voices of older adults and decided to find ways for them to maintain their independence. A
new county property tax levy allows Joan and her colleagues to fund in-home services for low-income clients, services such as “life
lines” (medical alert systems), personal care, housekeeping, medical transportation, adult day care, home-delivered meals, and
assistance with bill paying. Through an effective educational campaign, taxpayers learned that it is more economical to provide
services for low-income older adults in their homes than to rely on residential care (assisted living, nursing homes) and emergency
hospital services.

Source: iStock Photo / FredFroese

Joan advocates for seniors to address their needs and rights for care. She visits senior centers and forums to promote and explain the
importance and virtues of the ESP. She works with provider agencies to ensure quality of care. At election time, Joan has used her
personal time to hang posters in the community and at polling sites to promote funding for the ESP.

The vast majority of Joan’s professional career has been dedicated to working with older adults. Providing support to older adults for
independent living is her passion. Ask yourself, do you have a passion for a population group or problem area? Would you be willing
to devote time, even if it involved your personal time, to political advocacy and action to promote your passion?

Several other features of generalist social work education and practice also are key to the APPM. The model
assumes that advocacy activities, whether for client access to services or promotion of policies and programs,
are conducted in an ethical manner. The APPM supports ethical behavior in assessing problems and
strengths, planning strategies for change, and addressing dilemmas.

Social workers are also assumed to be critical thinkers with the ability to communicate effectively through oral
and written means. In other words, social workers engaged in advocacy must be able to integrate multiple
sources of information into a clear and coherent action plan. Furthermore, that action plan must reflect the
interest of clients and connect individual needs to systematic change.

Recognizing the effect of diversity and culture in shaping life conditions is a particularly critical element in the
APPM. Specifically, social workers engaged in advocacy must recognize their own values and biases and not
let them influence their work. The APPM advances human rights by underscoring the need for social workers
to understand various forms of oppression and discrimination, including their own prejudices.

As in generalist practice, the APPM uses concepts and insights from the person-in-environment approach to
design research methodologies and program evaluations. The findings from the research inform practice and
policy initiatives. This research also ensures that clients and the broader society will be exposed to scientifically
tested intervention strategies throughout the change process.

172

Social Work in Action

173

Competing Values and Goals in Advocacy
Thomas is a social worker with an adoption agency. Today’s court appearance is to advocate for the adoption of Jimmy, a 2-year-old
boy, by Jill, a 30-year-old lesbian foster care mother. Jill has raised and cared for Jimmy for more than a year and lives in a discreet,
committed relationship with her female partner.

Jimmy’s birth mother is a crack addict, and her whereabouts have not been known for well over a year. In the past, this adoption
judge has shown reluctance to approve adoptions without a biological parent’s written consent and for gay or lesbian parents.
Thomas’s assessment and adoption study clearly indicate that Jill will be an excellent mother and that it is in the best interest of
Jimmy (the client) for his adoption by Jill to be approved.

Although Thomas believes in the rights and merits of gays and lesbians’ adopting children, in this example of case advocacy, his
focus is on Jimmy’s best interests, not on promoting or advocating for gay and lesbian adoption. Thomas is prepared to present the
judge with all relevant information that will support Jill as an adoptive parent and, if necessary, debunk myths associated with gay
and lesbian adoption. However, for Jimmy’s interest and welfare, Thomas does not see this court appearance as an opportunity for
larger-scale advocacy to advance (beyond Jimmy’s adoption decision) the judge’s views about gay and lesbian adoption. Indeed,
Thomas has determined that dwelling on the sexual orientation of the adoptive mother in this instance would be inappropriate and
potentially jeopardize Jimmy’s adoption.

Exhibit 4.1 Theoretical Framework for the Advocacy Practice and Policy Model

174

The Cycle of Advocacy

The change process for generalist practice, introduced in Chapter 3, can readily be adapted to guide social
work advocacy and link practice goals and outcomes. Exhibit 4.2 illustrates the five steps in the intervention
process in terms of the APPM. As in generalist practice, intervention is a dynamic process. The exhibit
highlights the importance of considering both problems and strengths, and the encompassing nature of people
and systems involved in advocacy—individuals (the micro level), families and groups (the mezzo level), and
organizations, communities, and societies (the macro level).

The feedback loop (in Exhibit 4.2, the dotted line that links evaluation and assessment) is very important in
advocacy as in generalist practice. The greater the number of people collaborating in the change process, the
more likely that adjustment and compromise will be necessary (Brydon, 2010).

In many ways, the cycle of advocacy describes a framework for guiding behaviors conducted by clients or
collaborators in conjunction with a social worker. The success of the planned action is judged by the answers
to such questions as, “Did the strategies work?” “Have life conditions improved?” and “Did systematic changes
occur?”

One social work researcher and educator (Brydon, 2010, p. 129) suggests that practitioners follow these
guidelines for increasing the effectiveness of the advocacy cycle:

Begin collaboration. Think about the big picture and what might be different.
Use your management and program planning skills to implement change. Ensure that there are review
and evaluation criteria.
Reflect on theory and practice. Apply critical and reflective approaches to review your practice
experience.

Exhibit 4.2 The Intervention Process and the Advocacy Practice and Policy Model

Collect and analyze evidence. Use your micro skills and research skills to gather evidence.
Begin advocacy. Use your engagement skills to begin to persuade decision makers.

Nancy, in her advocacy regarding the licensure of social workers, followed most of Brydon’s suggestions. She
began by collecting relevant information and collaborating with key stakeholders. Both activities are labor-
intensive. She became especially aware that building relationships with key stakeholders can be a challenge. In
Nancy’s state, politicians and decision makers are aware of their power and often guarded about forming new
relationships or being courted by people aligned with special interest groups. Indeed, many legislators employ
a chief of staff who serves as an official gatekeeper and controls contact with them. Nancy was aware of these

175

challenges, however, and spent extra time figuring out how to link her cause to the legislators’ interests.

Time to Think 4.4

Although many social workers enter the profession to help others, producing and consuming research are integral functions in
contemporary social work practice and advocacy efforts. Do you possess an interest and aptitude for research and statistics, or the
willingness to produce and adopt research in practice?

176

The Advocacy Model in Action

Ask your family members, friends, and acquaintances about their perceptions of social workers and social work
activities. They are likely to affirm that social workers are problem solvers, helpers for people trying to address
daily needs, therapists, caseworkers, group workers, community organizers, and advocates for change to better
people’s lives and promote and advance human rights. Even relatively uninformed members of the general
public will acknowledge that social workers are professionals willing to stand up and advocate with and for
oppressed and disadvantaged groups.

It is far less clear to most people, including many helping professionals, how advocacy is integrated into social
work practice. In this book, advocacy is broadly defined as actions taken to defend or represent others to
advance a cause that will promote social justice (Hoefer, 2012, p. 3). More specifically, social workers promote
fairness, secure needed resources, and empower people (especially members of disadvantaged groups) to take
an active role in decision making. Some of the specific advocacy activities that social workers pursue in
everyday practice, as well as in their efforts to advance policy development, are captured in Exhibit 4.3.

Although this list of advocacy activities looks straightforward, it is important to realize that conflicting goals
and values often complicate advocacy. Social workers live and work in their own social worlds, which are
frequently distinct from the social and economic realities of their clients. To support client self-determination,
social workers must often ignore their own interpretations of the environment and commit to advocating for
change based on the hopes, ambitions, desires, and interests of their clients. The social worker (or the agency)
and the client may have “competing and sometimes contradictory values” (Boylan & Dalrymple, 2011, p. 20).
When the values of clients conflict with professional values and ethics, social workers typically seek guidance
from supervisors, professional ethics panels, and legal staff.

Keep in mind that advocacy typically occurs with clients and not simply for them. Although there are
exceptions to this premise (e.g., mentally challenged clients and very young children), social workers make a
special effort to ensure that client self-determination and the will of the client remain at the forefront of all
forms of intervention, including advocacy. A social worker whose activities to advance the interests and rights
of a client or population group have become misaligned with the desire and will of clients often ends up in a
lonely place.

Exhibit 4.3 Advocacy Activities in Social Work

177

Hoefer (2012) suggests that advocacy takes place through education, negotiation, and persuasion. Common
techniques used by social workers to influence others concerning client causes include documentation of
issues, provision of expert testimony, letter writing, use of social media, telephoning, promotion of voter
registration, face-to-face lobbying (e.g., individually and at hearings), economic and social support of
politicians, becoming an elected official, and involvement in political parties and functions. As with much of
social work practice, strong interpersonal skills are vital. Social workers need to be able to listen to others,
form relationships, capture thoughts, and communicate in clear, concise, and convincing ways via written
word and oral presentation. Advocacy often involves calculated decisions as to whom should be contacted,
how, when, where, and for what purpose(s).

178

Tenets of Advocacy Practice and Policy Model

One of the signature themes of this book is the special place advocacy holds within social work practice. In
each of the chapters that follow, you will find a section that examines a particular practice population, need, or
setting in terms of four basic philosophical principles, or tenets, that many social workers embrace. The
diagram in Exhibit 4.4 depicts the dynamic advocacy model, a way of conceptualizing advocacy, and its four
interlocking tenets—economic and social justice, a supportive environment, human needs and rights, and
political access—to ensure ethical and effective practice. We say that these tenets are dynamic because they
tend to shift constantly; we say that they are interlocking because it is hard to draw clear boundaries between,
for instance, political access and economic and social justice.

We have identified tenets of advocacy that social workers often routinely use as a score sheet for their
endeavors on behalf of a case or a cause. For instance, “Does my work promote economic and social justice?
Does it promote a supportive environment, human rights and basic needs, political access?” There are other
tenets that can motivate and guide advocacy, but this model helps aspiring social workers understand some of
the most important elements associated with advocacy and policy practice.

It is important to point out that the four tenets identified in our dynamic advocacy model are not purely
distinctive or independent. Instead, in social work practice with real people and situations, these tenets have
considerable overlap with and influence on one another. For example, one’s political perspective and
involvement influence the definition of and thinking about economic and social justice. And environmental
factors and context impact the conceptualization of economic and social justice in a specific time and place.
The intent of the dynamic advocacy model presented throughout this book is to prompt critical and
multidimensional thought and discussion about advocacy in social work practice.

Exhibit 4.4 Dynamic, Interlocking Tenets of Advocacy Practice and Policy Model

179

180

Economic and Social Justice

Social justice is a core value of social work, as expressed in the Code of Ethics of the NASW (2018):

These activities seek to promote sensitivity to and knowledge about oppression and cultural and
ethnic diversity. Social workers strive to ensure access to needed information, services, and
resources; equality of opportunity; and meaningful participation in decision making for all people.
(“Ethical Principles”)

In the APPM, the tenet of economic and social justice is closely related to the NASW definition of social
justice. It involves “promoting and establishing equal liberties, rights, duties, and opportunities in the social
institutions (economy, polity, family religion, education, etc.) of a society for all [people]” (Long et al., 2006,
p. 208). Justice includes relational justice, which is people’s ability to exert influence over decision-making
processes and in relationships with dominant groups. Economic justice is captured in the concept of
distributive justice, which is the ability to allocate or spread resources, income, and wealth in a manner that
ensures people’s basic material needs are met.

When social workers advocate for social change with clients, these activities should be justice centered.
However, what does “justice centered” really mean for advocacy practice? Because there are a multitude of
issues associated with economic and social justice, this is often a challenging question for practitioners. We
can say that just practice involves equality, tolerance, and the promotion of human rights, as well as an active
attempt to overcome social and economic inequalities (Finn & Jacobson, 2008).

Social work scholars have proposed a number of schemes for determining the degree to which advocacy is
justice oriented. One of them (Hoefer, 2012, p. 80) emphasizes these four key aspects of social justice: respect
for basic human rights, promotion of social responsibility, commitment to individual freedom, and support for
self-determination. Scoring systems have also been devised for monitoring advocacy practice based on the type
of justice being pursued (economic justice, distributive justice, relational justice, and so on), the strategy
employed, or the underlying principles (Reisch, 2002, p. 350). Whichever scoring system is used, the point is
that professional social workers need a way to determine whether advocacy has lived up to the tenets they
espouse. The social and economic checklist might include the following:

Am I sensitive to my client’s right to think and act independently?
Am I supporting equality of opportunity for my client?
Am I encouraging my client’s meaningful participation in decision making?
Am I helping my client unearth opportunities for economic and social justice?
Am I helping my client secure needed resources?
Am I ensuring that all parties’ rights are being respected?
Am I advancing thought about the need for social responsibility?

Let’s return to Nancy’s advocacy for improving the licensure law in her state. Her motivation is firmly rooted

181

in the tenet of economic and social justice and her desire to promote just practice. Many of her clients have
received inferior services and experienced limited opportunities. She is dedicated to people’s receiving
effective, high-quality services from professional social workers who have earned appropriate degrees and
credentials. Nancy also believes the meaningful participation of clients in decision making about the
implementation of programs and services can best be accomplished by properly educated and trained social
workers. Clients deserve and have a right to receive as high a quality of service as possible.

182

Supportive Environment

The term environment is abstract, expansive, and loosely defined; yet the concept pervades social work theory
and practice. Dominant theoretical approaches for intervention include the ecological perspective and the
person-in-environment perspective (see Chapter 3). The underlying idea is that social work involves not just a
client but a client system—all the people and social systems surrounding that client (e.g., significant others,
friends, families, groups, churches, companies, associations, organizations, communities, societies), as well as
natural and tangible resources (e.g., funds, land, buildings, time, computers, goods, water, food, housing,
clothing). A thorough assessment and holistic awareness of the environment is essential for contemplating and
enacting change.

Current Trends

183

Natural Disasters
Severe natural and weather-related circumstances—floods, tornados, earthquakes, wildfires, hurricanes, typhoons, blizzards—are
often catastrophic environmental phenomena. People who are affected need immediate emergency services, water, food, shelter,
clothing, medical assistance, and mental health services. Organizations such as the American Red Cross and World Food
Programme provide aid to communities devastated by these crises. Many social workers receive advanced training for responding to
crises and implementing crisis intervention services.

Identify a recent natural or weather-related catastrophe that concerned you, and identify the organizations, professionals, and other
people who responded to the needs of the people affected by this natural disaster. As an example, with Hurricane Sandy—a powerful
storm that hit the northeast coast and New Jersey and New York shorelines in 2012—social workers partnered with the Red Cross
and numerous crisis relief agencies to address the basic needs of people affected and to provide counseling. Social workers also
advocated for the immediate availability and implementation of state and federal relief services and funds.

Note, advocating for resources to assist victims of natural and weather-related trauma is a year-round activity. Is this an area of
interest for you in social work practice?

For social workers engaged in advocacy and policy practice, an environmental perspective leads to the premise
that clients need a supportive environment. Any key part of a client’s environment that is not supportive needs
to be considered. Social workers must be in tune with the social and physical conditions, human relationships,
and interaction patterns involved in any aspect of social work practice, including advocacy. Ask yourself:

Has a determination been made in collaboration with the client about which elements of the
environment are currently supportive and which are detrimental or not as supportive as possible?
Are existing resources available to advocate successfully?
Is collaboration occurring to generate ideas for solutions and to make reasonable and effective choices
about courses of action?
Am I examining with the client ways to work with people and organizations to create a more supportive
environment?

Nancy is encouraged that her social work colleagues, the state NASW chapter, a handful of elected state
officials, and a couple of consumer groups want to pursue licensure reform for social workers in her state.
However, she is cautious about and sensitive to the timing of a legislative initiative. She is undertaking this
advocacy effort during a period of restricted funding for social services. Nancy sees social workers and clients
who are overwhelmed by day-to-day operations and struggling to provide effective services in their agencies.
Additionally, fiscally and socially conservative politicians are reluctant to advance legislation that would
contribute to additional spending, or the expansion of regulatory bodies and the state bureaucracy. She and
her colleagues must formulate a strategy for not only strengthening ties with allies but also approaching the
skeptics and persuading them to change their minds. She knows how important creating a supportive
environment will be for the success of her initiative.

Time to Think 4.5

Social workers are often thought of as people willing to do good for others, which often means that others expect them to be willing
to do good 24/7/365. Professional social workers must learn to maintain boundaries for relationships with clients and use of personal

184

time. Contemplate your use of time, especially in relationship to potentially labor-intensive activities such as advocacy. Are you able
to effectively set boundaries between personal and work time? For example, do you currently text message or e-mail family and
friends during class time or at work? During personal time, are you tethered to work, answering work-related text messages and e-
mails at all hours? If you were passionate about a cause, as Nancy is about licensure for social workers, would you be texting and e-
mailing people all the time? What are the possible consequences of these kinds of behaviors?

185

Human Needs and Rights

Human history is full of instances in which well-intentioned people (often white men) from dominant classes
established programs and services for people they determined to be in need. People in positions of power and
policymakers often decide who has needs, what is needed, and how programs and services should be
implemented and evaluated. These top-down decision-making processes yield disconnects between how
clients view their own needs and what others believe they deserve.

In contrast, the perception and reality of human need from the client’s point of view is the primary concern of
social workers. Need is to be framed in the spirit of what the person in need requires, not what others believe
that person deserves or should receive. Social workers contemplating human need would ask these questions:

Who is defining the need and for whose benefit?
What are the consequences for the client of such a definition of need?
Are consumers of services being included or consulted when defining what is needed?

As important as it is to address the immediate human needs of clients in social work practice, doing so can
often overshadow the relevance and importance of human rights and liberties (Murdach, 2011). It may appear
that social work’s dual obligations to address human needs and advance human rights are consistent and
complementary, but in practice advancing human rights can too easily become secondary to the quest to
address the immediate needs of clients.

Basic human rights can be thought of in a number of realms, such as personal, civil, and political rights.
Generally, however, humans should be able to live free of persecution, discrimination, and oppression, and
have access to important societal resources, which often include work, education, health care, and equality
before the law. For many people and professions around the globe, an important source for defining and
advancing human rights is the United Nations and the UN Human Rights Council, which disseminates up-
to-date information and news about basic human rights. From a social work practice perspective, a key to
promoting basic human rights is the ability for people to have meaningful participation in decision-making
processes, which typically includes freedom of thought and expression.

The integration of human rights into the activities of social work practice has not been easy, especially in the
United States (Witkin, 1998). In an individualistic and capitalistic society such as the United States, the
general public and social workers tend to conceptualize human pain and suffering as the result of the
individual’s psychological makeup and choices in life rather than as the result of an unjust society (Witkin,
1998). Nancy, this chapter’s featured social worker, believes that clients are people deserving of dignity.
Clients have the right to receive high-quality services from competent and effective helping professionals.
Advocating for the licensure of social workers in her state is one way of promoting professional services that
recognize and support client respect, understanding, self-determination, and rights.

186

187

Political Access

The crass reality of macro-level decision making in much of the contemporary United States is that relatively
few people have sufficient power to dictate policies, laws, and administrative orders. This situation exists in
city, county, state, and federal governments as well as many private organizations and entities. Unfortunately,
the primary interest of politicians (and CEOs and board members, in the case of private organizations) may
not be what is best for the general welfare or for your clients. Instead, self-preservation, public perception and
opinion, and reelectability (especially for politicians) or profitability (for CEOs) are often powerful concerns.

Politicians are elected because of their ability to acquire support and funding from others; CEOs are typically
chosen because of their ability to focus on profits. Especially in the case of politics, being a candidate generally
requires a considerable amount of funding and support from “heavy hitters” willing to donate appreciable
money and time to the campaign. Of course, politicians are inclined to lend their ear and afford influence to
major contributors. Politicians often feel beholden to longtime friends, loyal allies, dedicated supporters, and
leaders of special interest groups and political action committees who have worked on their behalf. Often, key
decision makers and policymakers meet with their allies and contributors to discuss “what ought to be” prior
to asking for general input and taking a formal vote or action during a public forum or meeting—a practice
sometimes referred to as “the meeting before the meeting.” In such circumstances, newcomers and people
outside of a politician’s inner circle find it difficult to exert influence and sometimes even to provide
information. Exhibit 4.5 describes the basic process for creating federal legislation. Consider where and how
in this legislative process U.S. Senators and Members of the House Representatives are influenced by “heavy
hitters” and financial supporters.

As a student considering the profession of social work, you might be asking yourself, “So what can I do to
effect political change? Wouldn’t it be a better use of my time to focus just on helping clients access existing
services?” But consider that not becoming politically involved or active—through apathy, ignorance, or
cynicism—can also be viewed as a political act. Effective social workers identify ways to become politically
involved and develop political access for their clients as a means for “creating a dialogue and solution that view
societal and structural inequities as the fault needing the fixing, not the people” (Haynes & Mickelson, 2006,
p. 4).

Mary Richmond, one of the founders of social work, was impatient with “do-gooders” who gave little thought
to the causes of their clients’ troubles (Haynes & Mickelson, 2006, p. 5). Today, social workers are enjoined to
care for their clients while advocating for clients’ access to, and influence within, the political process. A
scorecard for this kind of intervention might ask the following:

Am I assisting clients to understand the bigger, fuller context of their problems?
Am I facilitating the collaboration of others who have similar challenges or who work to overcome these
kinds of challenges?
Am I assisting clients with communicating their predicaments to politicians and policymakers?
Am I enabling politicians and policymakers to look beyond these clients’ situation to assess the

188

structural and systemic issues contributing to the creation of private troubles?

To accomplish their goal of instituting a licensure requirement for social workers in their state, Nancy and her
colleagues need to influence key political decision makers. Nancy has already completed a considerable
amount of research to identify state legislators aligned with policies that are consistent with a new and
improved licensure law for social workers. The voting patterns for state legislators are very clear and
consistent. Proponents and supporters of social legislation aimed at protecting and advancing rights and
opportunities for consumers of social services and programs come from progressive urban areas. Opponents of
social legislation are elected in affluent, conservative, suburban and rural areas and frequently vote against
government intervention.

Personally, Nancy has been considering the actions she is willing to take to achieve her goals. She is prepared
to give expert testimony before legislative bodies or committees interested in examining the licensure issue.
She is brushing up on the skills she needs to lobby legislators, being especially attentive to innovative forms of
communication involving new technology and media. To learn more about the use of technology for lobbying,
she plans to enroll in two new continuing education workshops examining the effectiveness of social media.
Nancy has begun to assess the political action groups and special interest committees that might be good allies
in the licensure cause. She has also considered running for the state legislature herself, or encouraging or
supporting someone with similar views to do so. She knows that her willingness to participate in the political
process is necessary.

Exhibit 4.5 A Basic Overview as to How Federal Legislative Bills Become Laws

Summary

The next time you hear someone suggest that social work sounds like an easy major, explain that the actions of social workers
significantly impact lives and that the professional accreditation requirements by the Council on Social Work Education are high.
Social work students are required to demonstrate their ability to perform specific practice behaviors, among them advocating for
their clients and for communities. Social workers do not just match their clients with available resources; they actively attempt to
change “the way things are” to improve their clients’ lives and communities.

Advocacy requires value orientation, ethics, knowledge, skill, and passion. This chapter provides only a sprinkling of what is expected
of social work students in terms of advocacy. As a beginning, however, the advocacy practice and policy model and the dynamic
advocacy model derived from it provide conceptual orientations for entertaining the value and effectiveness of a social worker’s
advocacy efforts on a client’s behalf. In the following chapters, these models are adapted to guide social workers through advocacy
activities in relationship to particular social welfare issues. Regardless of the issue, advocacy should be collaborative, client centered,
and ethical, and should act to help people in need.

189

190

Top 10 Key Concepts

absolute needs
advocacy
basic human rights
case advocacy
cause advocacy
cost of advocacy
dynamic advocacy model
economic and social justice
relative needs
social action

191

Discussion Questions
1. Identify the causes for which you feel particular passion (e.g., feminism, gay rights, gun rights, benefits for veterans, racial

discrimination). Why do these causes seem particularly relevant to you? Consider your geographical location, current social
conditions, and aspects of your own identity.

2. Is it possible to separate personal from professional values in practice, especially when engaged in advocacy? Identify a couple of
personal values that would challenge your ability to advocate for a client population.

3. Can you hold conservative political views and be an effective social worker? How about an extreme or radical perspective?
4. Does the current “safety net” of services in the United States address the absolute needs of people in our society? If not, which

groups of people are falling through the safety net? To what degree are people’s relative needs being met?
5. Should everyone holding the title of social worker be professionally educated in a program accredited by the Council on Social

Work Education? Should government agencies and social welfare organizations reimburse only licensed professionals (e.g., social
workers, counselors, psychologists, nurses) for services?

6. Would you ever consider running for a political office or becoming a volunteer for a political party? How might your sentiment
affect your ability to be an effective social worker and advocate for causes?

7. On the website for your school, closely examine the research requirements for a BSW or MSW degree. Is this coursework
congruent with your passion for helping others?

192

Exercises
1. Consider attending a rally or some form of public advocacy event. Can you identify the objectives and desired outcomes of the

gathering? Are social workers involved in the demonstration? How do you explain their presence or absence?
2. Contemplate attending a political fund-raiser or rally for a candidate. Be attentive to the seating arrangements and interaction

patterns of participants. Is there an “inner circle” of confidants surrounding the politician? How are those in attendance given
opportunities to ask questions or enter meaningful dialogue with the candidate?

3. Many schools offer a legislative day in the state capitol. Sessions allow students to listen to legislators and their legislative aides
describe how the business of state government and the legislative branch takes place. Attend and ask questions about effective
ways to become involved in political processes. How challenging do you think it would be to get involved? What seems to be the
secret to accessing decision makers and policymakers?

4. Select a human service organization in which to serve as a volunteer. Observe social workers at the agency and inquire about their
typical workday and workweek. What kinds of activities do they perform? Use the chart in Exhibit 4.6 to record information about
their time spent in activities such as advocacy and policy practice. Ask them directly, if necessary. In summary, how much of their
work is related to advocacy?

5. Attend a service learning immersion class, such as an “urban plunge” or trip abroad, that will expose you to people who have
serious unmet absolute needs. As an alternative, talk with someone who has already had this type of experience. How does it
challenge your thinking about the need to advocate for human needs and rights?

Exhibit 4.6 Time and Advocacy Activities of a Social Worker

Online Resources

The Advocate, a national gay and lesbian magazine (www.advocate.com): Exemplifies the use of technology to promote
awareness and advocate for rights
Council on Social Work Education (www.cswe.org/Accreditation): Provides background about social work accreditation and
links describing the criteria and expectations for the accreditation of educational programs in its Educational Policy and
Accreditation Standards, including the competencies and practice behaviors required in social work curricula
Evangelical Lutheran Church in America (www.elca.org/Our-Work/Publicly-Engaged-Church/Advocacy): Promotes social
justice and advocates for ideals and values aligned with faith
National Association of Social Workers (www.naswdc.org/advocacy/default.asp): Recommends ways to become involved in
advocacy as a social worker
Political Action for Candidate Election (www.naswdc.org/pace/default.asp): Provides information about social work
participation in political processes and recommends action to elect candidates

Student Study Site

193

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

194

Part 2 Responding to Need

Chapter 5: Poverty and Inequality
Chapter 6: Family and Child Welfare
Chapter 7: Health Care and Health Challenges
Chapter 8: Physical, Cognitive, and Developmental Challenges
Chapter 9: Mental Health
Chapter 10: Substance Use and Addiction
Chapter 11: Helping Older Adults
Chapter 12: Criminal Justice

195

Chapter 5: Poverty and Inequality

Source: Mario Tama / Staff / Getty Images

196

Learning Objectives
After reading this chapter, you should be able to

1. Define the term poverty.
2. Describe who is considered an individual and why.
3. List various factors associated with poverty.
4. Define at least five programs or services designed to address poverty.
5. Apply the dynamic advocacy model to poverty and inequality.
6. Describe the role of social workers in addressing issues of poverty.

Steve Sees the Face of Poverty

Steve was not a likely candidate to begin his social work career in Appalachia, the region around the mountain range in the United
States that stretches from the southern tip of New York to northern Alabama, Mississippi, and Georgia. Raised in an affluent
community just north of Manhattan in New York, Steve wanted to work in the coal fields of Appalachia because he was intrigued
with the resilience that seemed to come from living in isolated communities, as he imagined the coal camps to be.

Steve discovered that generalist social work positions were available in the rural towns he visited. In part, this was because there were
few graduate social work programs in the region, and people who earned a master’s degree in social work did not necessarily want
employment in rural communities such as the coal towns or coal camps. Eventually, Steve accepted a position with an outreach
program operated by a community mental health center located in a county seat nestled in the Appalachian foothills. He was
supervised about 1 hour each week by a psychologist. The majority of people served by the agency were long-standing residents of
the area with large and often complex family systems. Steve’s social work position required that he conduct home visits to people
with persistent mental illness, many of whom had been institutionalized for a significant period of time in one of the state’s large
mental health facilities. Steve had to be quick thinking, flexible, agile, and resourceful on the job if he was to succeed, since the
demand for services was high, the needs of people were multidimensional and often generational, and supervision was limited at
best.

As a generalist social worker in the Appalachian region, Steve quickly learned that although America is one of the wealthiest nations
in the world, it is also a country plagued by poverty. By visiting people in their homes and assessing their strengths and weaknesses
within communities, Steve saw that prosperity and wealth are enjoyed by only a small portion of Americans.

Social work has a long-standing commitment to address the common needs of people who are poor and
underrepresented. You will discover in this chapter that issues of poverty and inequality raise many concerns
with regard to human rights and social justice. In this way you will begin to consider that poverty involves
much more than money. Ideally, you will look beyond the symptoms to understand the root of poverty and
how social work attempts to reduce poverty and inequality by applying knowledge through skills in practice.

As you read this chapter and consider the relationship between poverty and inequality, take time to think
about the role of government in regulating fairness of opportunity and income. Generalist social work practice
provides you with a lens through which to glimpse poverty. Ideally, the content of this chapter will stimulate
new ideas and beliefs about the realities of poverty and alternative ways to frame the nation’s response to
common needs.

197

198

Poverty

Discussions of poverty evoke strong responses from those concerned with society’s welfare, such as social
workers, because of its crippling effect on life conditions. The debate surrounding what to do about poverty
reflects opinions on the role of government, government’s contract with its citizens, and the distribution of
wealth in the United States and other countries.

Poverty is not a new phenomenon, in our country or around the world. Yet the term poverty is difficult to
define in a concise manner. Usually we consider poverty in the context of being without basic needs or
resources such as money and all that it buys—food, clothing, housing, transportation, medical care. However,
defining exactly what are basic needs within those categories and how much should be spent on them fuels the
debate on poverty. As you probably see with your friends and family members, what is considered enough
depends on the person or group of people discussing the need and allocating the resources.

For example, a social worker may think basic needs include high enough wages to maintain a family with a
few comforts, a house in a safe area, and a brief, thrifty vacation every year, but an employer may argue that a
worker can survive on less and that raising wages to support the worker’s aspirations will prevent the business
from making a profit.

Most Americans do not know any poor people even though the number of people in poverty is increasing.
Insulation from poverty is not all that uncommon in America. The nation’s economic structure tends to
restrict the interaction of people living in poverty with those who are middle and upper class. In fact, just
mentioning poverty, individuals and families in poverty, and issues of inequality will cause many people to
change the subject abruptly. For this reason, we think it is critical for you to have an understanding of poverty
in America and of the social welfare programs and services designed to address poverty.

199

Measures of Poverty

Economists and the governments of the United States and most nations of the world generally define poverty
in terms of a quantitative measure referred to as absolute poverty. A fixed dollar amount, generally
representing a person’s wages, is used to designate poverty. The key factor in this absolute measure is
agreement on the exact number that determines who is impoverished and who is not.

In contrast to an absolute measure of poverty is the concept of a relative measure. Relative poverty compares a
person’s wages with the norm or an average to determine if that person is experiencing poverty. Defining a
relative level of poverty is extremely difficult, if not impossible. This is especially the case when you begin to
compare what would constitute poverty in one place with the living conditions in other places—especially
when comparing countries worldwide.

In 1963 the United States adopted the notion of a poverty line, sometimes referred to as the poverty
threshold or poverty index, under the direction of Mollie Orshansky, director of the Social Security
Administration (Orshansky, 1964). Each year the poverty line is adjusted to account for inflation. It is used by
social welfare agencies and programs to determine a person’s eligibility for benefits and services. Those whose
income is above the poverty line do not receive services, or they receive lesser benefits than do those who are
below the poverty line. The process of determining who qualifies for services and who does not is referred to
as means testing. Means testing attempts to reduce some income inequality through the provision of services
and benefits, but in no way does it attempt any major redistribution of wealth. For many social workers,
documenting need through means testing is a hindrance to establishing rapport, because they must ask people
personal and often intrusive questions about their income levels, expenditures, and insurance benefits.

The poverty guidelines are another federal poverty measure. They are issued each year in the Federal Register
by the Department of Health and Human Services. The guidelines, a simplification of the poverty thresholds,
are used to determine financial eligibility for certain federal programs and for other administrative purposes.
Oddly enough, because the poverty guidelines vary from state to state, some people are poor enough according
to federal guidelines to fall below the poverty line and receive services but not poor enough by state standards
to receive other services.

Definitions of poverty and the way society responds to social need are based on assumptions and subjective
values that constantly change over time. However, the poverty line remains useful. The measure helps in
gathering data on the number of people experiencing poverty and the services people have requested and
received or were denied. Reviewing the data provides a picture of poverty trends over time. The data also
underscores poverty’s relationship with quality of life and life choices, and the link between poverty and
inequality.

Time to Think 5.1

Take a moment to consider your definition of poverty and how you would describe poverty to someone. Is your definition based on
personal experiences, readings, observations, or things people have told you?

200

Measuring poverty and determining who is a poor person reflects values and beliefs. How are your values reflected in your definition
of poverty?

Do you think addressing poverty issues such as homelessness should be a priority of government? Why or why not?

201

Poverty and Inequality

The distribution of income and wealth in the United States covers a wide spectrum. In this context, wealth
refers to the accumulation of valuable resources and possessions, whereas income is a wage for work provided.
Income is the money that flows into a household in a year, while wealth pertains to assets accumulated over
time, such as stocks, houses, savings, and cars.

The U.S. Census Bureau aggregates the data on income and wealth and divides the nation’s population into
quintiles, or fifths. The “top quintile” is the top fifth of the population based on income and wealth; the
“bottom quintile,” which is the lowest fifth, is generally the target of programs for those who are poor. What
analysis of the data has shown for decades is considerable, and growing, inequality in the distribution of
wealth and income in the United States. The distribution of wealth is more unequal than the distribution of
income, with the majority of wealth owned by about one tenth of the nation’s population. Exhibit 5.1 depicts
this inequality. What is important for you to remember is that while some people are very wealthy, others
have accumulated essentially zero wealth.

This increasing inequality in income and wealth translates to a decline in opportunity for poor people.
Consider these economic facts (Stiglitz, 2012):

Income growth is occurring primarily within the top 1% of the income distribution.
The unequal distribution of income results in growing social inequality.
Inequalities are apparent not just in income but in other factors that reflect standards of living, such as
housing and health.
There is little income mobility: People who are poor have few opportunities to invest their money and
make it work for them. They are unable to move up the economic ladder into a higher economic status.

As a result, the United States has more inequality than any advanced industrialized country, and it does less
than other countries to correct these inequalities (Stiglitz, 2012, p. 25).

202

The Face of Poverty

No matter what your political leaning is, you probably recognize that equality is basic to American beliefs.
However, poverty is real in the United States, and it is not evenly distributed across the population. The
questions you, as a potential social worker, should be asking are, “Who are the nation’s people living in
poverty?” and “Why are they poor?” To answer these basic questions, we look at the groups who are likely to
experience poverty.

Exhibit 5.1 Demographic Makeup of the Population at Varying Degrees of Poverty, 2015

Source: U.S. Census Bureau, Current Population Survey, 2016 Annual Social and Economic
Development Supplement.

Time to Think 5.2

Describe what the face of poverty looks like to you. Is it a woman, man, or child? What age is the person, and how does he or she
appear?

Now consider where you got the ideas for your face of poverty. How did your life experiences, social media, films, books, and other
representations influence your thinking?

Women

Throughout history and across the nations of the world, women are more likely to experience poverty than are
men. This tendency is described as the feminization of poverty (Pearce, 1978).

A primary reason for this state of affairs is the difference in average earnings or income for women versus
men. Women in the United States still earn only 77 cents on the male dollar. This figure drops to 68 cents for
African American women and 58 cents for Latinas. Some of the discrepancy is due to discrimination against
women in some higher-paying occupations. Women who can find work only in low-paying jobs experience a
ripple effect of disadvantage: in lifetime wages, savings and investments, retirement benefits, and other types
of wealth. The result can be a state of persistent poverty. If they cannot afford the many expenses associated
with car ownership, they find that public transportation is extremely limited and incredibly time-consuming.

203

The barriers to gainful employment are even more complicated when combined with race, leaving a distinct
pattern of poverty for women of color (see Exhibit 5.2).

In addition, women tend to be at a disadvantage in the workforce due to societal changes in family structure—
namely, high rates of divorce and separation and out-of- marriage births. Single and divorced mothers are
more likely to be responsible for children than fathers are, and this extra responsibility places an additional
economic burden on them. Working mothers who are on their own often struggle to find and pay for quality
child care. And when a family experiences a crisis that requires home-based caregiving, as when a child or
parent suffers a chronic illness—women are usually the ones to leave the workplace to provide the care at
home.

Exhibit 5.2 Female-to-Male Earnings Ratio and Median Earnings of Full-Time, Year-Round Workers
15 Years and Older by Sex: 1960 to 2015

Source: U.S. Census Bureau, Current Population Survey, 1961 to 2016 Annual Social and Economic
Supplement.

People of Color

A history of prejudice and discrimination in the United States has largely disconnected people of color, such
as Hispanics and African Americans, from economic opportunity and upward mobility. The concentration of
minorities who are poor and live in certain neighborhoods has worked to enhance the disadvantages. Social
services, public transportation, and quality health care may not be available close by. Often the schools in
impoverished minority neighborhoods are substandard, because the property taxes generated from the local
residents cannot support high-quality schooling. A substandard education, in turn, chokes off the opportunity
to succeed in occupational training programs and other advanced educational opportunities. Financial barriers
to college are also a problem.

Without a good education, it is difficult to secure a well-compensated job. Decent employment, with benefits
such as health care and retirement funds, is necessary for people to move beyond financial insecurity. The
crippling of unions in some occupations has had a disproportionate effect on people of color in low-paying
jobs, who usually lack the individual clout to advocate for better wages.

204

Although the media often depict the individuals who are poor as people of color, the majority of the people
who are poor are white. However, people of color are disproportionately poor. In the case of Native
Americans, about 30% of all families are living below the poverty level. Exhibit 5.3 compares poverty rates for
people of color in the United States.

Children

Poverty among children reflects the feminization of poverty. As can be imagined, caring for children is often
costly, especially for working single mothers, and children’s demands on parents’ time can negatively impact
parents’ earning abilities.

Exhibit 5.3 Poverty Comparison from 2013 to 2015

Source: Adapted from Federal Safety Net, n.d.

Efficient and economical transportation is important to the quality of life of all people.

Source: iStock Photo / ThaiBW

In the past 20-some years, economic trends have hit families hard—particularly those families with young
children, where the parents are usually young as well. The United States has experienced significant increases
in unemployment and a general decline in the economy. Even when parents are employed, more of them have
to work a second job to help make ends meet. Consequently, it has been increasingly difficult to support a
family.

205

Unfortunately, children represent a disproportionate share of those living in poverty in the United States; they
are 24% of the total population but 36% of the poor population. As shown in Exhibit 5.4, the poverty rate for
children varies substantially by race and Hispanic/Latino origin, as it does for adults.

Although their group is not included as a separate category in Exhibit 5.4, American Indian children
experience a very high level of poverty. In the states of Arizona, Minnesota, Montana, Nebraska, New
Mexico, and North and South Dakota, more than 50% of American Indian children live below the poverty
line.

People Who Are Homeless

It is logical to think that poverty is a major contributor to homelessness. According to the U.S. Census
Bureau, homelessness has worsened in the past decade because of increased housing costs, unemployment,
and foreclosures, which were a result of the Great Recession and real estate meltdown starting in 2008. A
number of factors continue to influence the homeless rate on a national level:

Unemployment persists, particularly among those with little education or training and those who are
older and have been unemployed for a long time.
Average real incomes for the working poor have increased by less than 1% since 2008.

Approximately 30% of Native American families live below the poverty line.

Source: Visions of America / Contributor / Getty Images
Poor households are spending more of their income on rent.
Foreclosure activity continues.
Stocks of affordable, suitable housing units for families have decreased.

There is no easy answer to the question of how many Americans face homelessness. According to the
National Coalition for the Homeless (2009), homelessness tends to be a temporary, rather than permanent,
circumstance. The appropriate measure of homelessness is, therefore, not a static number but, rather, the
number of people who experience homelessness or substandard housing conditions at any given time.

Time to Think 5.3

Given the picture you now have of poverty, what approaches would you support to address it? Consider why you selected these
approaches.

Exhibit 5.4 Poverty Rates by Age and Sex, 2015

206

Source: U.S. Census Bureau, Current Population Survey, 2016 Annual Social and Economic
Development Supplement.

Children make up a disproportionate percentage of the poor population, at 36%.

Source: iStock Photo / BrandyTaylor

While homelessness affects people of all ages, races, ethnicities, and geographies, inequality is part of the
homelessness equation. The people at increased risk of being homeless are those living in “doubled-up”
situations (living with friends, family, or other nonrelatives for economic reasons), people discharged from
prison, young adults leaving foster care, and people without health insurance.

207

Social Service Programs for the those Who Are Poor

As mentioned in Chapter 2, Americans began to broadly address poverty in the colonial period, through the
Elizabethan Poor Laws. Today’s social welfare programs originated with the New Deal of the 1930s.
Programs to prevent poverty, usually referred to as social insurance—such as Social Security and workers’
compensation—were designed to reward work and were funded through payroll deductions. People who could
not work outside of the home—such as women with young children, people with disabilities, and older people
—were thought to be the deserving poor and were provided for through public assistance, or means-tested
programs.

The primary goal of programs designed to aid the people who are poor, particularly when women and children
are involved, has been to support the American economic and social systems, rather than to redistribute
resources or change the value structure. People are always encouraged to work and participate fully in the
economic system. Assistance programs by and large are designed to tide people over in times of downturn, not
to redistribute wealth from the rich people to the poor individuals.

However, the American social welfare system was built on the fear of dependency on the government,
government reluctance to provide social services, the work ethic, and rugged individualism. It is no surprise,
then, that the system lacks coordination, cohesiveness, and a common sense of purpose. Today, federal public
assistance efforts comprise as many as 75 different programs. They include the distribution of cash payments,
direct services such as health care or training, and vouchers that can be converted into commodities such as
heat, food, and clothing. Public assistance is also not so much a system as a network that operates across the
federal, state, and local levels, and sometimes involves all three in a single program.

Before discussing each specific program, it is important to clarify some common values and perceptions of
antipoverty programs. The American public has been reluctant to provide assistance to people who are poor.
The distinctions between the worthy and unworthy helped ensure that only people deemed “truly deserving”
of assistance received it. The past 10 years have witnessed increasing levels of public frustration and
resentment directed toward antipoverty programs and the individuals who are poor themselves. Today the
term most often used to describe efforts to assist the people living in poverty is welfare. Welfare has now
become a vague, overarching term that stigmatizes people and conjures up images of handouts given to people
who are marginally deserving or not deserving at all.

208

Temporary Assistance for Needy Families

The largest, and perhaps most controversial public assistance program, is commonly known as Temporary
Assistance for Needy Families (TANF). It was established through the Personal Responsibility and Work
Opportunity Reconciliation Act, which was part of the welfare reform legislation of 1996, passed during the
Clinton administration. The TANF program replaced Aid to Families with Dependent Children, the Job
Opportunities and Basic Skills Training program, and the Emergency Assistance program.

Designed to help families experiencing poverty achieve self-sufficiency, the TANF program provides states
with block grants, which are large sums of money to be used for social services but without specific directions
for how to spend the money. TANF funds are to be used to design and operate state programs with these
goals:

Assist those families that are needy so children can be cared for in their own homes
Reduce the dependency of parents in need of assistance by promoting job preparation, work, and
marriage
Prevent out-of-wedlock pregnancies
Encourage the formation and maintenance of two-parent families

Social Work in Action

209

William George Researches Poverty So He Can Help the People Who
Are Poor
William George works in a county human services department in California. His clients include many single mothers and their
children, many people of color, some people who are disabled, some parolees and veterans who cannot find jobs, and some people
who are homeless. Uniformly, they are poor.

William George has become disillusioned about his ability to help his clients. There are programs in place that could relieve their
suffering, but due to budget cutbacks in federal and state programs, he simply cannot find all the needed help for his clients in a
timely manner. He decides that he needs to push his concerns into the spotlight. But first he needs more facts and figures to bolster
his campaign.

There are several social work institutes dedicated to understanding the dynamics of poverty, including the following:

Gerald R. Ford School of Public Policy Programs on Poverty and Social Welfare Policy
National Center for Children in Poverty
Institute for Research on Poverty

William George carefully notes data on poverty in his state, as well as details about the various populations that face difficulties in
finding jobs, housing, health care, food, and other necessities. (The information in this chapter about the face of poverty is similar to
what he finds; you might also wish to check these websites for additional information.)

William George realizes that he needs to narrow his focus to be effective. If he attacked poverty in general, he would likely never
make a dent. So he resolves to pick an impoverished population or a cause of poverty or an aspect of need created by poverty.

1. If you were William George, how would you narrow your focus? Which group or groups would you concentrate on? Why do
you choose that group?

2. Make a list of the aspects of life that contribute to poverty for that group. For example, how do age, education, residency,
and gender impact the financial security of an individual?

3. What aspects of poverty would you like social workers to research? Why?

There is no guarantee that eligible individuals will receive assistance under TANF. The state-by-state system
of determining need allows states to provide monthly payments only to the people who are the poorest of the
poor and who are thought to be the truly needy. In fact, according to federal law, families who have received
five cumulative years of assistance will no longer be eligible to receive cash aid, federal funding for TANF
block grants is capped at a set amount, and states must require adult recipients of TANF benefits to work
after 2 years on assistance. Penalties for failure to work are set by each state.

Individual recipients who are unable to engage in work activities can elect to participate in community service
or 12 months of vocational training, or they can provide child-care services to individuals who are
participating in community services. As odd as it sounds, TANF does not provide child care, although single
parents with children less than 6 years of age who cannot find child care will not be penalized for failure to
engage in work activities.

210

Medicaid

The Medicaid program was an addition to the Social Security Act of 1965. It provides federal matching funds
to states to cover the costs of medical care and services for low-income people (Centers for Medicare and
Medicaid Services, 2014), including the following:

Children: Medicaid and the Children’s Health Insurance Program provide health coverage to more than
31 million children, including half of all low-income children. An outreach program is in place to enroll
eligible children in coverage.
Nondisabled adults: Medicaid provides health coverage to 11 million nonelderly low-income parents,
other caretaker relatives, pregnant women, and other nondisabled adults.
Pregnant women: Medicaid plays a key role in child and maternal health, financing 40% of all births in
the United States. Medicaid coverage for pregnant women includes prenatal care through the
pregnancy, labor, and delivery, and for 60 days postpartum, as well as other pregnancy-related care.
Individuals with disabilities: Medicaid provides health coverage to more than 8.8 million nonelderly
individuals with disabilities, including people who are working or want to work.
Older adults and Medicare and Medicaid enrollees: Medicaid provides health coverage to more than 4.6
million low-income older adults, nearly all of whom are also enrolled in Medicare. Medicaid also
provides coverage to 3.7 million people with disabilities who are enrolled in Medicare, the federal health
insurance program for people 65 years and older.

Plans to replace the Affordable Care Act would give each state a fixed amount of federal money in the form of
a block grant to provide health care to low-income people on Medicaid. A block grant would be a significant
change to Medicaid funding. If Congress decides to create block grants for Medicaid, lawmakers will face
thorny questions with huge political and financial implications: How much money will each state receive?
How will the initial allotments be adjusted—for population changes, for general inflation, for increases in
medical prices for the discovery of new drugs and treatments? Will the federal government require states to
cover certain populations and services? Will states receive extra money if they have not expanded Medicaid
eligibility under the Affordable Care Act, but decide to do so in the future?

Medicaid provides coverage for essential care for pregnant women.

211

Source: Jana Shea/Alamy Live News

212

Supplemental Security Income

The Supplemental Security Income (SSI) program provides cash assistance to any person whose income falls
below the poverty line and is 65 years or older or is blind or has a disability. A person qualifies for SSI benefits
if he or she is unable to participate in paid employment due to a medically determined physical or mental
impairment or is over the age of 65. SSI also covers children with disabilities.

The various components of SSI were originally outlined by the 1935 Social Security Act. In 1972, the
consolidation of two different programs—Aid to the Aged and Aid to the Blind and Disabled—coordinated
eligibility and benefits under the federal government. Unlike many programs for poor people, funding for SSI
comes entirely from federal revenues and is administrated through the Social Security Administration,
resulting in uniform eligibility standards and benefits across all states.

213

Healthy Meals for Healthy Americans

Healthy Meals for Healthy Americans, funded by the federal government and operated by the states, provides
food, nutrition counseling, and access to health care to eligible women, infants, and children. This type of
program was first introduced in the social welfare system as the Special Supplemental Nutrition Program for
Women, Infants, and Children (known as WIC). Initially a pilot program, WIC was made a permanent
social welfare program in 1974. It is administered by the Food and Nutrition Service of the U.S. Department
of Agriculture. WIC’s name was changed under the Healthy Meals for Healthy Americans Act of 1994, to
emphasize its role as a nutrition program (U.S. Department of Agriculture, Food and Nutrition Service,
2013).

To be eligible, women and their children must be at nutritional risk and have income below state standards for
measuring need. The majority of Healthy Meals for Healthy Americans programs provide vouchers that
women use at authorized food stores. A wide variety of state and local organizations cooperate in providing
the additional food and health care benefits.

Healthy Meals for Healthy Americans has proven effective in improving the health of pregnant women, new
mothers, and infants. Studies show that women who participated in the program during their pregnancies
incurred lower Medicaid costs for themselves and their babies than did women who did not participate
(California WIC, 2012). Participation in the nutrition program was also linked with fewer premature births,
higher birth weights, and lower infant mortality rates.

Time to Think 5.4

The United States is fortunate in that the country provides enough food to feed its entire population. Why do you think women and
their children, as well as other sectors of society, such as older people, are still at nutritional risk? What are some of your ideas to
improve the availability and accessibility of food across the nation?

214

Supplemental Nutrition Assistance Program

The Supplemental Nutrition Assistance Program (SNAP), formerly known as the Food Stamp program,
helps low-income people buy food. SNAP—the nation’s first line of defense against hunger—is a vital
supplement to the monthly food budget for more than 46 million low-income individuals. Nearly half of
SNAP participants are children, and more than 40% of recipients live in households with earnings below the
poverty line.

Developed as part of the New Deal, the program was originally designed to distribute surplus agricultural
goods according to federal standards and under the direction of state or local agencies. Support for
government involvement in the purchase of food came from agricultural groups as a way to guarantee prices
for farmers during periods of overproduction. Agricultural support for the food program resulted in its
administration by the U.S. Department of Agriculture.

To participate in SNAP, a person must be determined eligible by income and be either a U.S. citizen with a
Social Security number or a U.S. national or qualified alien. The SNAP application process includes an
interview and documentation, including personal identification, such as a driver’s license; proof of income for
each member of the household; proof of child-care costs; rent receipts or mortgage payments; records of utility
costs; and medical bills for household members 60 years or older and for those who receive government health
care.

215

Earned-Income Tax Credit

The Earned-Income Tax Credit (EITC) helps families who experience poverty in spite of having working
family members. The general goal of the federal EITC program is to allow low-wage workers to keep more of
their annual earnings. Thus, the program acts as a wage supplement for people in low-wage jobs and can
decrease poverty for working families. The tax credit legislation was passed to offset the burden of Social
Security taxes for low-income workers and provide an incentive to work. Congress originally approved it in
1975 and has expanded it several times since.

Social service programs for mothers and children, such as Healthy Meals for Healthy Americans, have proven
to improve the health of pregnant women, new mothers, and infants.

Source: iStock Photo / RuslanDashinsky

The EITC is administered by the Internal Revenue Service (2014). Participation requires the filing of a
federal tax return and involves the same procedures as paying federal taxes. When the EITC exceeds the
amount of taxes owed, the filer qualifies for a credit. The tax credit is based on family income and the number
of children.

216

Public Housing

With the U.S. Housing Act of 1937, the federal government began financing low-income public housing.
The Department of Housing and Urban Development (HUD) Act of 1965 expanded the program by creating
HUD as a cabinet-level agency (U.S. Department of Housing and Urban Development, n.d.-b).

The federal government offers programs where individuals may rent housing at rates based on their after-tax
income.

Source: iStock Photo / jrling

People who qualify can rent a home (known as Section 8 housing) through HUD, with rental charges set by
the federal government at about 30% of a person’s monthly after-tax income. The federal government
provides rental certificates and vouchers that can be used to subsidize the lease of a privately owned rental
unit.

The Stewart B. McKinney Homeless Assistance Act, enacted by Congress in 1987, established distinct
assistance programs for the growing numbers of homeless persons (U.S. Department of Housing and Urban
Development, n.d.-b). It was the first comprehensive federal effort to aid people who are homeless. Included
in the McKinney Act are 20 programs, including emergency food and shelter, transitional and permanent
housing, education, job training, mental health care, primary health care services, substance use treatment, and
veterans assistance services.

217

Diversity and Poverty

In this chapter we have already learned about how diversity intersects with poverty. Women, people of color,
children, and people who are homeless are all more likely to experience poverty than are other population
groups. We have also seen the pernicious effects of intersections of diversity, such as the greater poverty
experienced by women of color.

For social workers, being able to apply the concept of intersections of diversity to social work practice and to
issues of poverty is not simply a benefit to people who are poor but a benefit to society as well. For example,
when considering the wages of women, it becomes necessary to examine wages for all people across a spectrum
of ages, working conditions, skills, and educational levels. A female client could be experiencing
unemployment or underemployment based on several seemingly unrelated factors, including not only her
gender but also disadvantages accrued from childhood poverty, such as a deficient education. Intervening by
offering literacy services might be a good supplement to job counseling and training for jobs that are not
traditionally held by women. Ideally, by thinking about intersections of diversity and women as workers we
gain a better understanding of economic inequalities and their implications for social status.

218

Advocacy on Behalf of the People Living in Poverty

We hope you begin to recognize that lack of earnings is by far the major reason why people are poor. When
considering employment status, wage inequality is a key factor, and wage inequality is associated with age,
race, gender, and family structure. Thus, it stands to reason that poverty disproportionately affects children,
minority groups, families headed by single women, and young families. These population groups are more
likely to encounter barriers to adequate employment in spite of wanting to work. So an increase in earnings is
the most expedient way to confront poverty and challenge inequality. (Exhibit 5.5 provides information on
federal poverty levels.)

Exhibit 5.5 Age and Sex of All People, Family Members, and Unrelated Individuals Iterated by Income-
to-Poverty Ratio and Race: 2015 Below 100% of Poverty—All Races

Source: U.S. Census Bureau, Current Population Survey, 2016 Annual Social and Economic Supplement.

The persistence of poverty suggests that economic uncertainty extending beyond individuals and toward the
nation’s social and economic structure is a factor. Social workers, and the nation as a whole, must not be
concerned simply with poverty but with the risk of increasing economic insecurity for the entire society.

Why don’t political and economic systems address poverty and inequality? The explanations span the
ideological spectrum. Conservative ideology is likely to argue that people who are poor are uninterested in
working because the public assistance system provides enough income for an adequate living, thus limiting
incentives for securing employment. This perspective focuses on individual motivations. A more liberal
ideology would suggest that structural barriers, such as the inability of the market to generate enough jobs and
an inadequate minimum wage, are a large part of the issue (Stiglitz, 2012).

219

Current Trends in Advocacy With People Who Are Poor

Social workers have come to understand the importance of not just learning about the services available to
individuals and families in need but also studying poverty. The best way is to learn from those who know best
about poverty and injustice: those who live in poverty. Living among individuals who are poor is referred to as
the accumulation of life knowledge (Krumer-Nevo, 2005). Integral to life knowledge are the interpretations,
meanings, hypotheses, analyses, and theories provided by the people experiencing the life conditions that
come from economic insecurity (Beresford, 2000). Understanding such life elements sheds light on the power
structure and the resources of people living in poverty, and challenges preconceived notions of poor people as
the “other” (Krumer-Nevo & Barak, 2007; Lister, 2004).

The ideas and perceptions gathered from life knowledge help form the social constructs, or perceived social
reality, that social workers have about poverty and inequality (Hacking, 1999; Searle, 1995). Social constructs
are important because they reflect beliefs. If the commonly held belief is that people are poor because they are
lazy, social welfare policies will be punitive and less inclined toward fairness in the distribution of resources. If
the public belief is that poverty is the result of failures in the marketplace, economy, or political arena, social
welfare policies will emphasize the value of equality. It is in the interest of social workers and the social work
profession to link life experience to social constructs to better shape government attempts to create a fair
society (Bullock, 1995; Groskind, 1994; Stiglitz, 2012).

Another point to consider is how life knowledge nurtures the development of skills needed for social work
practice at all levels—from direct services with people to policy development. For example, a social worker
with life knowledge who was involved with a program for people who were homeless would become mindful
of how micro-level work to change an individual situation is connected to advocacy for macro-level policy
change. The skills developed through life knowledge also help social workers develop partnerships with people
in service communities and with programs across multiple levels of government, allowing them to share power
and privilege to achieve effective interventions and social change (Krumer-Nevo, Weiss-Gal, &
Monnickendam, 2009).

Time to Think 5.5

Life knowledge is gathered from our first memory and throughout our lifelong development. Consider some of the skills you
attribute to life learning. Where did you gather these skills and from whom?

220

Dynamic Advocacy and Poverty

Considering all the policies and programs the United States has in place to address issues of poverty, you
might be wondering why so many Americans still live in poverty. Answers to that important question are
found by examining the point where poverty intersects inequality: people working at low-paying jobs, single-
headed households, and the fraying social welfare safety net. All three of these broad categories
disproportionately impact women, children, and minority groups in both rural and urban areas.

The advocacy and policy practice model, described in detail in Chapter 4, is designed to assist social workers
in analyzing and advocating for policies and services that help alleviate poverty. Ideally, applying the model to
social constructs or beliefs about poverty enhances the integration of micro and macro social work practice to
effect change in individual lives and in social, economic, and governmental arrangements.

Two broadly opposing values, personal responsibility and social responsibility, have prominently influenced
public policies regarding poverty:

Personal responsibility refers to the role people have in caring for their own needs, no matter the
circumstances that have left them in need. Americans believe strongly in individualism, which is the
belief that hard work is rewarded with success, virtue will also bring success, failure demonstrates a lack
of virtue, and lazy and incompetent people attain success only through luck (Wilensky & Lebeaux,
1958). In essence, according to individualism, success or failure depends on the individual. Thinking
about poverty in this context, we would see individuals, families, and possibly neighborhoods as being in
charge of not only their employment status but also their health care, mental health, and housing.
Social responsibility, in contrast, contends that society should assist those experiencing unfortunate or
challenging circumstances (Segal & Brzuzy, 1998). It supports a collective approach to addressing need.
It is important to realize, however, that social responsibility extends only to people considered to be
worthy and by definition unable to support themselves because of age, disabilities, or child-care
responsibilities.

Social welfare advocacy reflects the struggle between individual and social responsibility. Those with
conservative beliefs oppose broad-based policies and programs that expand the role of the federal government,
believing that they nurture dependency rather than self-reliance in those who receive services. In contrast, a
more liberal perspective supports an expansive role for government and for policies and programs with more
universal coverage, such as Social Security. The tension between conservative and liberal policy positions plays
out differently in different eras, depending on the political and economic environments.

Time to Think 5.6

If you think of the conservative and liberal stances on individual and social responsibility as being two ends of a spectrum, where do
your beliefs fall? Which social programs do you think are good for society, and which are destructive?

Economic and Social Justice

221

Of the four tenets of the dynamic advocacy model, economic and social justice is perhaps the most basic. It
underpins social work’s professional commitment to helping people enhance their quality of life by addressing
problems and matching resources with needs. Economic and social justice is based on a sense of fairness and
the belief that people, no matter what their gender, race, age, or abilities, deserve equal economic and social
rights and opportunities.

Social workers advocating for economic and social justice at the macro level address these particular questions
(Kahn, 1994):

How the power structure responds to the needs of individuals who are poor
How the power structure has changed to address issues of inequality
How well social welfare agencies are addressing the needs of people living in poverty
How the power structure recognizes and responds to the voices of people with low incomes and their
organizations
How well the power structure recognizes and involves the leaders of people living in poverty, such as
clergy and union leaders
How well individuals who are poor are represented in positions of power within the community

Current Trends

222

Life Knowledge
Increasingly, students are taking a “gap year” in between high school graduation and college. Also, some college students decide to
spend a year or more engaging in volunteer work as a life experience and a way to enhance their résumés. In either case, programs
such as the Peace Corps, Volunteers in Service to America (VISTA), and Teach for America offer life knowledge experiences. They
provide potential social workers, as well as anyone who wants to make a difference for the poor, with opportunities to learn firsthand
about the struggles that some people face just to meet their basic needs:

Peace Corps—International volunteer service primarily in developing nations. Requires a college degree and a 2-year commitment.

Volunteers in Service to America (VISTA)—Volunteer service in the United States. Requires at least a high school diploma.

Teach for America—Teaching commitment in often poor or vulnerable communities. Requires a college degree.

1. You may wish to review these programs online and consider if their mission and goals correspond to your career plans. What
do you find?

2. Some universities have programs for returning Peace Corps volunteers that provide credits for participation as part of
graduate coursework. Does your university have such a program?

3. What other experiences have given you or could give you life knowledge that applies to work with impoverished people and
communities?

Advocacy for clients involves referrals to other social welfare agencies to ensure that people experiencing
poverty have the services they need, such as access to food stamps and health care. It can also mean protection
from financial abuse by credit card companies, banks, check-cashing establishments, student loan companies,
and mortgage lenders. Finally, social workers are called on to ensure that clients receive the financial benefits
owed to them from insurance policies and union membership.

Social workers also apply social justice principles to structural problems in the social service agencies in which
they work, focusing on the long-term goal of empowering their clients. Social workers readily use their
knowledge of legal principles and organizational structure to suggest changes that will protect their clients,
who are often powerless and underserved. For example, a generalist social worker at a mental health clinic
might help ensure that clients are treated respectfully by staff by negotiating with the clinic’s director to
appoint a client to the community governing board.

Supportive Environment

Social workers learn that their role is often to work with networks of people, in families, communities, and
regions. Whether a problem is an individual issue or relevant to a group of people, the challenge is to help the
community, when at all possible, define the situation in communal terms and take action that will support
individuals in need (Ginsberg, 2001).

Environmental factors may influence the types of jobs available in a community.

223

Source: iStock Photo / Thanmano

One of the advantages of working in communities is that many social work clients know one another. This
sense of interconnectedness is generally positive. When the community is not supportive, the social worker
has a point for assessment and possible change.

To form a social construct of how the area’s overall environment addresses poverty and helps those who are
poor, social workers can compose a list of questions that identify strengths and problems. The goal is to
compile an objective profile of the area and its citizens to show the ways economics and politics are
interrelated. The following questions illustrate how social workers might ask clients, colleagues, and
community leaders about support for employment in a certain area (Kahn, 1994):

Describe the jobs available for people who want to work.
Do these jobs pay minimum wage or above?
What are the working conditions for the available jobs?
What are the opportunities for employment for women, minority and ethnic groups, teenagers and older
people, and people with mental health challenges?
Describe the benefits—for instance, health and mental health insurance—offered by the employers.
What types of transportation to these workplaces are available?
What are the day-care options in the community?
What are the skills associated with these employment opportunities?
What sorts of training programs currently exist in the community, and what programs are needed?

Social workers recognize that fostering jobs within the community is essential to reducing persistent and
tenacious poverty. The connection of environmental factors to policy responses on employment requires broad
community participation, greater opportunities, and more empowerment of poor people in their own
development process. True to social work’s principles on equality, the goal is to enhance economic
development within a community.

Human Needs and Rights

Americans embrace the idea that all people are entitled to certain human rights regardless of nationality, sex,
national or ethnic origin, race, religion, language, or other status. Those rights include civil and political
rights, such as the right to life, liberty, and freedom of expression, and social, cultural, and economic rights,
including the right to express one’s culture, the right to food, and the right to work and receive an education.

224

International and national laws and treaties uphold and protect human rights in most other parts of the world.

Social workers understand the concept of the indivisibility of rights. In their practice they see that civil rights
without the security of food, shelter, and health care do little to enhance well-being. An advocacy orientation
is perhaps the greatest social work strength and one that can make important contributions to human rights.
Social workers take action; they engage in securing human rights for individuals and communities. What is
missing is the ongoing link to build on individual case solutions to influence policy change.

The universality of human rights was first emphasized in the Universal Declaration on Human Rights in
1948, and has since been reiterated in numerous human rights conventions, declarations, and resolutions.
Social workers often apply three key principles to their work, which are taken from the 1948 declaration and
supported by the U.S. Department of State (2012) in its dealings with other countries:

Learn the truth and state the facts in all human rights investigations.
Take consistent positions concerning past, present, and future abuses.
Maintain partnerships with organizations, governments, and multilateral institutions committed to
human rights.

These principles provide social workers with a moral foundation for human rights practice, both at the level of
day-to-day work with clients and in community development, policy advocacy, and activism (Ife, 2001).

Despite the array of programs that have been developed to alleviate poverty, social workers inevitably find that
some services cannot meet common needs of the people who are poor, such as food, housing, and medical
care, in a timely manner. The service system is driven by bureaucracy and thus inflexible. In addition, the
service system tends to minimize client needs, stigmatize those served, and intimidate clients with mounds of
paperwork.

Further, to address human needs and rights on a broader level, social workers will sometimes turn to the
lobbying arm of the National Association of Social Workers. The NASW lobbyist might help organize public
forums that nurture public trust and promote the idea that change is possible through collective action.

Political Access

The practice of social work generally heightens the consciousness of social workers about economic instability
and the alarming level of inequality in the nation. Looking at programs and how well they meet the needs of
their clients, social workers often question the nation’s essential fairness.

Many social workers find it increasingly difficult to ignore national and international poverty and inequality. It
often appears as though political structures and established agencies are not truly responsive to all members of
society. In fact, many of the funds that provide necessary services come through the federal government, and
funding allocations are far below the need and in most cases shrinking.

Social workers sometimes work on voter registration campaigns in the hopes that getting their clients and
people like them to vote will help change the equation in Washington, D.C., and in state legislatures. Clients

225

and sympathetic community members are recruited by asking three broad questions (Kahn, 1994):

What is your voter registration status?
If you want to vote, what is your name, address, and other contact information?
What is the contact information of any family member in the military, a nursing home, hospital, school,
or other institution who might want to register to vote?

Involving clients in voter registration campaigns also helps inform them of the positions of various candidates.
Candidates who have expressed support for the needs of poor people in their community are likely to attract
clients’ interest. Whatever the ultimate success of the candidate, social workers see people’s leadership skills,
self-esteem, self-confidence, and self-reliance evolve as they make their needs known and exercise their rights
through the ballot box.

226

The Cycle of Advocacy

Seen in its totality, the dynamic advocacy model shines light on the skills, values, client knowledge, problem-
solving orientation, and strengths assessments that define generalist social work practice. Social workers and
their clients, working together, have the ability to research and analyze poverty and inequality and to advocate
for change in people, communities, and agencies, and across all levels of government.

A first step in advocacy is envisioning improved conditions or a more ideal state of affairs (Jansson, 1999). For
example, when thinking about social justice and poverty, social workers can use their analytical skills to assess
structural problems in the agencies that serve their poor clients. The interactional skills of social workers often
lead to a network of colleagues in human services, as well as new referrals for clients.

Realistically viewing the political structures that shape the lives of people living in surrounding communities is
often a matter of integrating theory with practice. Social workers who apply different theoretical perspectives,
such as the strengths perspective and empowerment concepts, often discover that economic and political
systems are dysfunctional, exploitive, and unfair to many poor people.

Social work clients usually have limited experience with professionals and politicians; so they are reticent and
even fearful about expressing their wants and needs. However, with knowledge of human behavior, social
workers can identify strengths and leadership skills in their clients and mobilize them to vote and participate
in political campaigns. Engaging people living in poverty in the political process helps demonstrate their
potential voting power.

Another important element of the dynamic advocacy model involves ethics. The impact of poverty and
inequality violates social workers’ belief in a moral or just world (Rawls, 1971). Thus, social workers aim to
help relatively powerless groups, such as women, children, people of color, people with special needs, and poor
people improve their resources and opportunities.

Time to Think 5.7

Do you think social workers contribute to the understanding of poverty and inequality through their practice? Please consider why or
why not. What would you do differently to change attitudes toward poverty and inequality if you were in a social work position?

227

Your Career and Poverty

As you think ahead to graduating from college and entering the workforce, consider how your selected career
might help alleviate poverty and inequality. For social workers, poverty and inequality are at the core of their
professional lives. In counseling, social workers typically address financial matters and employment status in
relation to depression, anxiety, or life experiences such as domestic violence, substance use, and homelessness.
On the policy level, social workers advocate and lobby for regulations and programs that enhance the well-
being of people with limited resources.

You do not have to become a social worker to enter the Peace Corps or serve as a Volunteer in Service to
America. In either of these organizations, a good portion of your time will be spent examining international or
domestic distributions of resources. In most of the locales they serve, those resources are basics of life such as
food, water, and shelter.

No matter where your career takes you, you can help alleviate the consequences of poverty and inequality by
keeping the needs and wants of others in your thoughts and displaying concern in your actions. Volunteering
at a shelter, fostering a child, feeding and socializing with older people, and taking a stand on behalf of a
policy or program are all components of the effort to change society for the better. And they can all make life
a little better for those who have been forgotten.

Summary

If a society cannot help the many who are poor, it cannot save the few who are rich.

John F. Kennedy

Poverty and inequality are not new phenomena in our country. The historical debate over what to do about these interrelated issues
reflects the dilemma of reconciling unequal levels of power and privilege in the United States. Further complicating the task are
contending forces whose political values and personal beliefs about the causes of life conditions influence the actions we take as a
society.

If you conclude that the structure of the nation’s economic system results in poverty and inequality, your macro-level advocacy will
focus on far-reaching changes in policies relevant to the market and labor systems. If you think that individuals are responsible for
their own poverty, your advocacy will emphasize changing people’s behavior. Unfortunately, neither approach has been implemented
effectively, and a large number of people are still experiencing poverty.

228

Top 10 Key Concepts

absolute poverty
feminization of poverty
income
inequality
means testing
poverty
poverty line (poverty threshold or poverty index)
public assistance
relative poverty
wealth

229

Discussion Questions
1. Much of the issue of poverty and inequality has to do with the role of government. Should the government ensure an adequate

standard of living for all citizens? In responding to this question, first define the term standard of living, and then consider how
expansive you think the government’s role should be.

2. As an advocate for people experiencing poverty, toward which level of government (local, state, or national) would you direct your
activities? Why?

3. Federalism is a form of government that combines individual states and an overarching national government. What role does
federalism play in a democratic society such as ours? How does this relationship play out in U.S. programs and services to people
who are poor?

4. Would you advocate for an increase in the minimum wage? Explain why or why not, with reference to poverty.
5. What is the Trump administration’s position on poverty and assistance to people living in poverty? What federal action has been

taken to alleviate the nation’s inequality? Identify and discuss a current “hot topic” or piece of legislation that stands to further
economic inequality in the United States.

230

Exercises
1. Keep a log of your daily expenditures over a week. Given your cash outlays, do you have a sense of financial security or insecurity?

If you had to trim your personal budget, what expenses would you reduce and how? How would you describe your socioeconomic
level and why?

2. Take time to reflect on how your family’s economic status impacts your life options. List the advantages you’ve experienced and
also the challenges.

3. Read an editorial from one of the nation’s leading newspapers that apply to the content of this chapter. Write and share with the
class a letter of support or rebuttal to the editorial that expresses your thoughts in a clear, concise fashion.

4. Spend time examining the community you are most familiar with, such as the one you were raised in or the community where you
currently live. Consider your selected community in light of the dynamic advocacy model’s four interlocking tenets. Based on your
analysis, list at least four possible advocacy actions related to poverty and inequality that you could organize in your community.
What social work skills would you use in these advocacy actions? What results would you hope to achieve?

5. Consider attending a service-learning immersion class, such as an “urban plunge” or trip abroad that will expose you to dire
absolute needs. How do you think this type of experience might challenge your thinking concerning human needs and rights?

Online Resources

Children and poverty (www.globalissues.org/issue/2/causes-of-poverty): Focuses on the reasons children experience poverty,
from a family systems perspective
Factors associated with poverty (www.stanford.edu/group/scspi/): Conducts regular surveys and aggregates data on poverty
and factors associated with poverty
Gender and poverty (www.legalmomentum.org/women-and-poverty-america): Examines poverty as it relates to issues of
gender
Global poverty (www.globalissues.org/issue/2/causes-of-poverty): Describes the leading factors related to worldwide poverty
Worldwide data on poverty (databank.worldbank.org/data/): Provides comprehensive data on poverty experienced
throughout the world

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

231

Chapter 6: Family and Child Welfare

Source: iStock Photo / monkeybusinessimages

232

Learning Objectives
After reading this chapter, you should be able to

1. Define family in light of contemporary family structure.
2. Describe the tension between the rights of children and the rights of parents.
3. Describe services and programs designed to help children and families.
4. Describe the belief systems that underpin opinions about child and family services.
5. Identify how the education system could be improved to help families and children.
6. Explain how diversity affects family and child welfare.
7. Apply the dynamic advocacy model to family and child welfare.

Rosa Works to Strengthen Families for the Sake of Children

As a child protective services social worker, Rosa advances child safety and identifies ways to strengthen the ability of families to
protect children. People have often told Rosa that they don’t understand how anyone could possess the temperament to work all the
time with cases of child neglect and abuse.

For Rosa, one of the most difficult hurdles has been working with young children living in dire poverty. Most of the children
assigned to Rosa are under the age of 6 and live with a single teenage mother who has less than a 10th-grade education and little or
no employment history. Many of these children do not eat properly, live in substandard housing, struggle with basic medical care,
and receive little support or attention from their biological fathers.

Rosa is keenly aware of the effects of childhood exposure to traumatic events, such as verbal altercations, acts of violence in the home
and outside of it, and substance use. She knows how hard it is for children to live with caregivers struggling with mental health and
chemical addiction issues.

Although Rosa’s caseload of 23 children and families is very challenging, she is dedicated to her area of practice. She actively
advocates for meeting the unique social–emotional needs of young children in challenged families, as well as providing family aid and
support in the form of employment assistance, adult education, self-help, health care insurance, mental health services, housing, and
child care.

Interpersonal violence, poverty, and child maltreatment are just a few of the many issues social workers
encounter when working with children and families. This chapter examines how the definition of family has
changed over time and the diverse family types. Common problems facing the U.S. family, such as child abuse
and violence, are also explored, along with the services available to children and families. A central theme in
this chapter involves how social workers can advocate for children and families to create positive, lasting
change.

Historically, child welfare has been a common and popular field of practice for social workers in the United
States. Beginning in the early 20th century, protection of children from various forms of maltreatment and
exploitation became a major concern. The early 1900s were characterized by industrialization, urbanization,
and the rapid migration of people from various lands to an economically blossoming country. Economic
growth, social disruption, and family stress went hand in hand. As economic growth and expansion took
place, children were exploited for their labor in the workplace, and very young children often faced harsh and
neglectful living circumstances at home. These rapid and dramatic social and economic changes formed the
backdrop for child and family services in the United States.

233

234

Today’s Families

The definition of what constitutes a family has changed in recent years and is often a source of debate in the
United States. Most people would agree that a family is a social unit containing two or more members.
However, families can vary significantly in composition, complexity, and size. For example, families can
consist of a husband and a wife without children, cohabiting unmarried couples, single parents and their
children, couples with children and extended family members, parents with children from previous marriages,
and multigenerational family members. Although state laws differ concerning legal definitions, families also
include same-sex marriages and partnerships.

Generally, regardless of its composition, the family constitutes a social unit where people form relationships
and make a commitment to live together as a defined family group and provide for the group’s social,
emotional, and economic needs, including care of children. Given such a broad definition of family, it is
important to note that family structure may or may not be based on kinship, which is common ancestry,
marriage, or adoption. No matter how families are constituted, they are a critical reference group for their
members (Lamanna & Riedmann, 2012).

Traditionally, families have been classified as a nuclear family, in which one or more parents live with their
dependent children apart from other relatives, or an extended family, in which, in addition to parents and
children, other relatives live in the same household or in close proximity. Today, who can define what
constitutes a family and a marriage is a topic of considerable debate among politicians, religious leaders,
special interest groups, and people from various cultural backgrounds. Differing views on the issue are aligned
with personal or group values, belief systems, and experiences. People with a conservative ideology often
define families in more traditional ways, and people with a liberal ideology tend to define families in the
broader, more contemporary ways.

235

Diverse Family Forms

The traditional image of family is a young husband and wife, each married for the first time, with one or two
birth children of their own and living in a single dwelling. That image has been undergoing change. Because
of advancements in communication and transportation, family units are not confined to single dwellings such
as houses or apartments. Some families have been affected by transnational migration for economic and other
reasons, a situation that separates family members into two or more countries (Furman & Negi, 2007). Also,
diverse forms of family abound in the contemporary United States (and perhaps always have). Separation,
divorce, blended families, single parenting, and gay and lesbian marriages are common occurrences. These
diverse forms of family composition also influence living circumstances.

Social workers practice with a variety of family types and need to be knowledgeable, nonjudgmental, and
competent in serving their needs. Each family form also possesses unique strengths. The social worker strives
to understand the challenges and abilities associated with each family type to promote and support healthy
child and family development.

Time to Think 6.1

What were your family circumstances growing up? Did you consider your family to be typical or atypical? Can you see strengths in
your type of family?

How did your family influence your values and outlook on life, including thoughts about career, marriage, and children?

Divorce

Once stigmatized as a sign of a failed marriage, divorce today is more commonly viewed as a legal process of
ending a marriage that allows spouses to become single and, if they choose, to remarry. Spouses seek divorces
for a variety of reasons, including unhappiness, infidelity, employment, unemployment, mental health,
substance use, interpersonal violence, disapproval of the relationship by relatives and friends, and newfound
romantic relationships. Another cause of divorce is irreconcilable differences, where the couple have
disagreements that cannot be resolved and neither spouse is blamed for the breakdown of the relationship.

Divorce need not necessarily be a negative occurrence or experience. Spouses can end relationships in amicable
ways that benefit them and other family members. In addition, divorce can represent an opportunity for
introspection and personal realization, especially with the help of professionals. This type of growth is useful
as a foundation for new committed relationships.

In the United States, the probability of a marriage ending in divorce is between 40% and 50%. Divorce rates
are traditionally lower for spouses with college degrees (Cherlin, 2010, p. 404).

Separation

Spouses may also seek a legal separation from each other, often as a precursor to divorce. Separation can be
temporary or permanent. Some states encourage or mandate a time-specific separation as a type of “cooling-

236

off period” for spouses to reflect on and examine their relationship and begin to define parameters for it.
Topics typically addressed include housing, living circumstances, and child visitation, financial commitments
(including financial support of children), distribution of possessions (e.g., furniture, electronics, cars, animals),
and banking accounts and loans.

Although physically separated, separated spouses maintain the legal status of being married. This is an
important attribute with regard to medical insurance, taxes, financial matters, and so on. As an example,
spouses may decide to separate rather than divorce to maintain satisfactory medical insurance coverage for
family members. Disruption in health and medical benefits and coverage could have a detrimental impact for
treatment and use of medicine, with powerful and potentially life-threatening results.

Blended Families

The term blended family typically refers to a family unit with two adults in a committed relationship, children
from previous marriages or relationships, and children (if any) from the newly formed committed relationship.
Blended families work hard to define the relationships of the children with their biological parents and
stepparents, as well as the relationships among the various siblings. Many children in blended families have to
share time between two families and two sets of parents, which necessitates planning and decision making
about activities, celebrations, holidays, and vacations. Social workers often work with blended family members
to help define reasonable and functional parental and childhood roles.

Divorce may offer an opportunity for introspection for the parties involved.

Source: iStock Photo / courtneyk

Single-Parent Households

When a family unit is headed by only one parent, it is referred to as a single-parent household. Typically, that
single parent is the mother. Without the help and assistance of a second parent, single parents face challenges
in caring for and financially supporting their children. In two-parent households, children have two caregivers,
and parents can rely on each other for social and emotional support.

However, an advantage of single parenting is that single parents have no everyday obligations and
commitments to a spouse. Advantages for children growing up in a single-parent household include the
potential to develop a sense of responsibility and independence at an earlier age.

Same-Sex Marriage and Parenting

237

Same-sex marriage is a relatively new phenomenon and an emotional and highly polarizing political issue. In
2004, Massachusetts became the first state to legalize gay marriage. Soon after, California and a number of
other states passed similar legislation legalizing same-sex marriages. Since the U.S. Supreme Court’s 5-4
decision regarding Obergefell v. Hodges in 2015, marriage for same-sex couples has been legal in all 50 states.

Social workers need to maintain an open mind about gay marriage and parenting. Gay parents are often
unduly placed under special scrutiny regarding their parenting practices. It is important to realize, however,
that same-sex parents, like heterosexual parents, can offer children a loving and caring environment for
growth and development. . . The creation and maintenance of a stable, nurturing, and loving family unit is the
key factor and does not depend on the sexual orientation of one’s parents.

Marriage Equality

Across the globe, a number of countries (e.g., Argentina, Canada, Mexico, New Zealand, South Africa, and
many European nations) have legalized same-sex marriage. However, marriage equality does not simply refer
to the legal right of same-sex couples to marry. Marriage equality also includes same-sex marriages having
equal acceptance, rights, and responsibilities as heterosexual marriages. For example, social acceptance of
same-sex marriages involves the use of welcoming and respectful language and nonverbal forms of
communication that promote and support the dignity and meaning of the marriage.

Cohabitation

When two adults decide to live together in a dwelling without legally formalizing their relationship through
marriage, they are cohabiting. Cohabitation continues to be very popular in the United States (see Exhibit
6.1) and is employed by many couples as a step between being single and being married. Other adults, for a
variety of reasons (e.g., lack of commitment, finances, legal issues, conflicting responsibilities) decide to forgo
marriage altogether and live together as a couple. Gay and lesbian couples residing in states that do not allow
same-sex marriage may have little other option than to cohabit.

Exhibit 6.1 Marriage and Cohabitation Among Women 15–44 Years of Age in the United States

238

Source: Copen, Daniels, Vespa, and Mosher (2012, Fig. 1, p. 5).

239

Family Problems

The family as a social structure is not necessarily declining in the United States, but it is most definitely
undergoing change. With all the contemporary variations in family structure, children and parents need a
range of programs and services that will help them adapt and adjust to new and evolving family roles and
responsibilities.

The family unit and its members also face many of the social and personal problems of the day.
Unemployment, poverty, mental health challenges, substance use, interpersonal violence, natural disasters, and
death of a loved one have powerful effects on families. Daily, family members struggle with these kinds of
tribulations in the context of their unique family constellation and home. Social workers are employed to
intervene with various family-based problems and advocate for programs and policies that strengthen and
enrich family functioning and promote the rights and safety of children.

Domestic Violence

Domestic violence is a general term that references a broad range of acts of violence (including assault, injury,
and rape) against family members. Predominantly, acts of violence are perpetrated by men and against women
and children.

Wives and children can be especially vulnerable to men in family constellations because of their economic and
social dependence as well as men’s physical dominance. Domestic violence is typically an issue of power and
control. Perpetrators take advantage of vulnerable people in the household as a demonstration of dominance
and the perpetrators’ desire to control family members’ behavior.

Child Maltreatment

Child maltreatment is a broad term used to encompass the abuse and victimization of children. Children are
vulnerable to several types of maltreatment because they are typically incapable of caring and advocating for
themselves, and instead rely on the adults in their lives. For much of history, the treatment of children was
considered a private matter. Children had no political power and no rights as independent human beings.
Most societies considered children to be the property of their parents (Miller-Perrin & Perrin, 2013). But
now their treatment has become a public matter as well as a private one.

The child-saving movement in the United States took place in conjunction with two noteworthy social
changes (Finkelhor, 2008). First, social workers, nurses, schoolteachers, counselors, and legal advocates
emerged as professionals and developed professional organizations devoted to seeking protection for children.
Second, women entered the labor force in greater numbers and acquired newfound power to advocate for
children’s rights. As helping professionals, child advocates, and child advocacy groups became more plentiful
and politically active, child maltreatment was criminalized, primarily through the passage of state-level child
protective statutes. The child-saving movement is viewed today as a mark of societal development and
modernization.

240

The practices, policies, and services put in place to promote child well-being and safety are generally referred
to as child welfare. Child welfare includes a complex array of services provided by publicly funded child
welfare agencies. Child protective services, programs through which social workers, law enforcement
personnel, and health care workers respond to reports of child maltreatment, are a key component in publicly
funded child welfare agencies.

Contemporary child welfare in the United States focuses on both children and families. The modern-day
family is conceptualized as an adaptable social system that can be both functional and dysfunctional for
children. For example, the family is the primary social unit for providing nurturance, sustenance, socialization,
and care for children. Yet the family is also the social unit where most child maltreatment occurs, and parents
are the primary perpetrators of violence against children 81% of the time (U.S. Department of Health and
Human Services, Administration for Children and Families, Children’s Bureau, 2011).

Current Trends

241

Child Trafficking
Child trafficking occurs when child victims are recruited, transported, harbored, and exploited. Child trafficking is often cited as a
contemporary form of slavery. Children are exploited for their labor, deployed as soldiers, and put to work in the commercial sex
industry as, for example, prostitutes, escorts, strippers, and nude models. The United States is both a source and a destination for
trafficked children, and it is also a transit country. It is estimated that more than 12 million people are the victims of human
trafficking worldwide, with more than a million being children, constituting a $32 billion worldwide trafficking industry (Catholic
Relief Services, 2014).

Many of the victimized children do not have families or caring adults to advocate for their protection and rights. Perpetrators of
child trafficking often take advantage of being the only adult figures active in the lives of these children, who are very vulnerable to
adult influence.

UNICEF has been a leading force in working to protect the lives of exploited children across the globe. Social workers partner with
organizations such as UNICEF to educate people concerning child exploitation and protection and to develop programs and services
to help these vulnerable and severely abused children. In the United States, UNICEF and helping professionals, concerned citizens,
and members of faith-based organizations have advocated for specific pieces of legislation. One success was the Trafficking Victims
Protection Reauthorization Act, signed into law by President Obama in 2013. This act supports the President’s Interagency Task
Force to Monitor and Combat Trafficking in Persons and serves as a major entity for coordinating antitrafficking programs and
initiatives.

Are you familiar with human and child trafficking issues and programs in your area or state? Is this a personal area of interest for social work
practice—why or why not? Discuss with classmates and friends how human and child trafficking is an affront to the dignity and worth of
people. How do people in the United States directly or indirectly support human and child trafficking––even if they do so inadvertently?

To understand child welfare, it is important to become familiar with several varieties of child maltreatment:

Child physical abuse: Deliberately using physical force that injures or could potentially injure a child
(Miller-Perrin & Perrin, 2009, p. 58). Examples of child physical abuse include forcefully hitting or
punching, kicking, shaking, throwing, burning, choking, and stabbing.
Child sexual abuse: Attempting (or succeeding in the attempt) to engage sexually with a child or to
exploit a child for sexual purposes (Leeb, Paulozzi, Melanson, Simon, & Arias, 2008, p. 11). Examples
of sexual acts include touching the genitals, engaging in sexual intercourse, penetrating the child,
sexually exposing oneself to a child, and engaging in voyeurism if a child becomes exposed or is engaged
in sexual acts.
Child neglect: Failing to meet a child’s basic needs (Miller-Perrin & Perrin, 2009, p. 152). Child
neglect can include but is not limited to failing to meet physical, emotional, educational, and medical
needs.
Child psychological maltreatment: Intentionally conveying that the child is “worthless, flawed, unloved,
unwanted, endangered, or valued only in meeting another’s needs” (Leeb et al., 2008, p. 11). Child
psychological maltreatment can include public embarrassment, verbal cruelty, intimidation, threats, and
deprivation of love.

Social workers practicing in child protective services receive special training for detecting and documenting
various forms of child maltreatment. They learn to be suspicious of bruises and injuries that simply do not
make sense or are illogical. For example, imagine that a parent claims that a small round burn on the child’s

242

arm was a result of play and skidding on the floor. The size, shape, and texture of the burn does not support
that claim and instead is consistent with a cigarette burn. Additionally, social workers look for behavioral
indicators of maltreatment, such as a child’s extreme passivity and withdrawal to avoid the attention and
provocation of a caretaker. Child protective social workers have a very demanding area of practice, and their
abilities and decisions directly influence the quality of life and safety of children.

Time to Think 6.2

Think about the factors that might motivate you to be a social worker. Do you think that working to make a difference in the lives of
children would match your motivations? Would a practice focused on abused and neglected children be problematic for you? If so,
why?

243

Child Welfare Services

In the United States, publicly funded child and family services are often the result of state or federal mandates
to protect and support the well-being and development of children. Public child welfare agencies typically
serve large numbers of people, offer a variety of programs, and are less costly to clients than comparable
private agencies. Public child welfare programs are often located in county-based departments of social or
human services and include adoption, family life education, foster care, child protective services, in-home
family-centered intervention, and residential services.

Conversely, private child welfare agencies usually focus on specific problems and subpopulations, rely on
private insurance and out of pocket fees for service, see fewer clients, and are less bureaucratic in nature. It is
not unusual for a social worker to develop professional expertise in practice with children and families in
public child welfare agencies and then be lured away to a private, more specialized child welfare agency.
Although salary and benefits for social workers in the public sector in departments of social services are often
very competitive, private agencies attract people through smaller caseloads, greater professional autonomy in
decision making, focused services, and less bureaucracy. However, many social workers are also dedicated to
providing clients reliant on public child welfare services with “top-notch,” quality intervention and services.

Time to Think 6.3

Would you feel more comfortable working in a public or private agency? Why? Consider the importance of factors such as
professional autonomy, mission, population served, salary, benefits, geographical location, and the degree of specialization in service
delivery.

244

History of Child and Family Services

In the United States, the development of child and family services can be traced to the early 1800s. Young
children were often left alone to care and fend for themselves while their parents worked or sought work,
sometimes traveling to the growing cities to do so. Older, more able-bodied children were exploited as a
source of labor in emerging industry. Powerless and vulnerable, many children found themselves without
basics such as food and shelter and in unsafe living conditions. The situation was so unacceptable that by the
mid-1800s government-run institutions were being established to house abandoned and needy children.

During the 1900s, abuse against children was defined as criminal. Considerable progress was made at the state
level to pass laws to protect children from abuse and neglect. Recognition by the states of their societal
obligations to protect those who were unable to protect themselves was an important step in the development
of child and family services. The stage was set for establishing procedures, funding sources, and policies to
intervene with children and thwart their exploitation and abuse.

In the 1960s, a more robust recognition of child abuse as a social issue occurred when Dr. C. Henry Kempe
identified the battered child syndrome as a clinical condition and advocated that physicians report cases of
child abuse to authorities (Kempe, Silverman, Steele, Droegemueller, & Silver, 1962). Battered child
syndrome can be a physical or psychological condition and typically involves persistent injuries (e.g., cuts,
burns, bruises, broken bones, and emotional abuse) inflicted on a child by a caregiver. In recent years, child
welfare researchers and neuroscientists have given considerable attention to shaken baby syndrome, where
infants and toddlers sustain serious brain injury as a result of being physically shaken.

With support from the powerful medical community, child abuse and protection became further recognized,
and by the end of the 1960s, professionals (e.g., social workers, physicians, teachers) were required to report
suspected cases of child abuse in every U.S. state (Miller-Perrin & Perrin, 2009, p. 16). Today, state statutes
also mandate that professionals report suspected elder abuse. Furthermore, there is emerging interest in cross-
sector reporting of various forms of interpersonal violence and animal cruelty. Veterinarians and animal care
professionals with reasonable suspicion of child abuse or neglect would be required to report to departments of
social services, and helping professionals with suspicion of animal cruelty would report findings to animal care
and cruelty organizations (Long, Long, & Kulkarni, 2007).

245

Parental Versus Child Rights

Attempts to protect children are complicated by the ongoing controversy over parents’ rights versus their
children’s rights. In the United States, parents are granted considerable latitude in disciplining and
maintaining control over the behaviors and development of their children. In some instances, parental rights
to exert discipline can supersede children’s rights to protection. Parents often assert the right to raise and
discipline their children as they see fit, and they can question oversight by social workers and other child
protection professionals. Some parents also attempt to justify child maltreatment as a parental right.

Spotlight On Advocacy

246

The Famous Mary Ellen McCormack Case
Although it is difficult to imagine, the United States has not always had policies to protect children from physical, sexual, and
mental abuse. The case of Mary Ellen McCormack in the late 1800s is frequently cited as a landmark case that brought attention to
the horrors of child abuse. Mary Ellen, a 10-year-old girl from the Hell’s Kitchen section of Manhattan, reported being the victim of
almost daily whippings and beatings by her adoptive mother.

Since child protection laws were nonexistent at the time, Mary Ellen’s case was brought to the attention of the American Society for
the Prevention of Cruelty to Animals, one of the few protective agencies in existence at the time. Eventually, Mary Ellen’s heart-
wrenching story made its way to a courtroom. Her case is credited as the impetus for the creation of the New York Society for the
Prevention of Cruelty to Children in 1874, which is believed to be the first child protective agency in the world (Markel, 2009). The
story was featured in an article in The New York Times on April 10, 1874.

Consider for a moment why the American Society for the Prevention of Cruelty to Animals was established in New York City before the New
York Society for the Prevention of Cruelty to Children. At that time, were parental rights for children’s upbringing and care more prominent
and powerful than today? For example, were whippings and beatings seen as acceptable? Are such abuse practices condoned anywhere today?

The overlapping needs and rights of parents and children are mirrored in the subtle (but important)
distinction between child welfare agencies and family service agencies. The mission of child welfare agencies
is to promote the safety, well-being, and best interests of children. Meanwhile, the mission of family service
agencies is to provide programs and services to support and strengthen families during challenges and
transitions. Although strengthening families and improving family functioning are important for promoting
the welfare and well-being of children, social workers are careful in practice to identify whether their client
system is the child or the whole family. The interests of families and other family members (particularly
parents) are sometimes at odds with the safety and best interests of children. For example, the rights of
parents to discipline children who are disrupting family life can conflict with the goal of child protection.

247

A Global Context for Child Protection

In the United States, childhood is often defined as the period from birth to age 18. The UN Convention on
the Rights of the Child (UNCRC) defines a child as a human being under the age of 18. However, the notion
of childhood can be conceptualized and defined in a number of ways. In some societies and cultures, the
dividing line between childhood and adulthood is less a matter of one’s age and more a rite of passage. For
example, children may become adults when they exhibit certain forms of physical maturation (such as the
emergence of secondary sex characteristics and ability to procreate) or have attained specific abilities (such as
educational attainment or work skills). Or a child may become an adult when called on, often out of necessity,
to fulfill vital roles as a caretaker of younger children or a provider for the family.

Around the world, there has also been considerable debate about what kinds of actions and behaviors
constitute child abuse and neglect, especially since cultures vary considerably in child-rearing practices.
However, the UNCRC has determined that all members of the United Nations must eliminate any customs
that are abusive to children and has created guiding principles to protect the safety and rights of children
across national borders (Miller-Perrin & Perrin, 2013, p. 10). Unfortunately, establishing widely shared
definitions of what constitutes “abuse of children” is an ongoing challenge.

You might be surprised to learn that the United States has been one of two countries (Somalia being the
other) to resist the ratification of the UNCRC treaty and policy statements promoting the protection of
children and nonviolent discipline. The United States has been reluctant to restrict the individual rights of
parents with regard to practices such as spanking of children (Miller-Perrin & Perrin, 2013, p. 11). For
example, fundamentalist Judeo-Christian religious traditions condone spanking and other forms of corporal
punishment as a means for creating discipline and making children more obedient.

The United Nations (UN) Convention on the Rights of the Child offers a list describing over 50 articles
(proclamations) of children rights, which can be found at
http://unchildrights.blogspot.com/2009/03/summary-childrens-rights-convention.html. UN articles of child
rights include many basic abilities; examples include protection from discrimination, the right to life, the right
to a name, freedom of thought, the right to privacy, and protection from various forms of exploitation.

Social Work in Action

248

Julian Supports HIV-Positive Children in Malawi
Especially in developing countries, HIV-positive children with HIV-positive parents are often left to cope on their own. They face a
double burden: the disease itself and its stigma, as well as life with chronically ill parents who often cannot adequately provide for
them (Rowan, 2013, p. 241). HIV-positive children living under such circumstances are helpless and shunned. Being a survivor
overshadows being a child.

As a social worker in Malawi, Julian has become very aware of these children and concerned about their bearing developmentally
inappropriate responsibilities for taking care of not only themselves but also a dying parent. “Child” under these circumstances seems
to Julian a misleading classification. This issue demonstrates how “childhood” varies and is relative to circumstances and context.

Much of Julian’s time is spent finding guidance and support for these HIV-positive children, often from extended family members.
As well as possible, Julian attends to the children’s basic needs and safety, while advocating for additional goods, services, and any
form of available social–emotional support.

Ask yourself, is it possible that in the United States, as in developing countries such as Malawi, some children could find themselves in
situations where they must fend for themselves to meet their daily needs? What kinds of circumstances would put children in the position of
assuming adult responsibilities over an extended period of time?

249

Key Child and Family Services

A variety of child and family services are offered in many counties and municipalities across the United States.
Social workers are employed both to provide these forms of services and to actively advocate for their
enrichment, resourcing, and effective use. As is the case regardless of one’s area of practice, social workers
helping provide these services to children and families typically begin their interventions with engagement and
assessment.

As you consider and reflect on your interests in social work with children and families, consider each of these
services as an opportunity for future professional development and employment. For example, can you
envision yourself working in child protective services, intensive treatment, or adoption services?

Child protective services. Social workers employed in public child protective (CP) services practice on the
“front lines” of child welfare and are exposed to a variety of forms of child abuse and neglect. When
child abuse or neglect is reported, CP social workers are the ones who help investigate the charges, take
the child into custody if necessary, and ensure that the child receives preliminary medical and
psychological services. CP social workers are typically required to complete special education programs
before employment. These education programs are often made available to social work students willing
to commit to public CP practice and are offered through training centers operated by the state
department of human services or departments and schools of social work.
Family-based services. This is a broad category of services that are designed to enhance and strengthen
the family unit, not simply children. Family-based services include counseling, therapy, skill building,
advocacy, educational, and other services for children, parents, and families. Family-based services can
be preventive and treatment oriented. Social workers are employed in a variety of public and private
family service agencies. Often the client’s ability to pay, either through medical insurance or out-of-
pocket, determines whether public or private services are used. Many counties and states also work with
school systems to organize and coordinate family-based services.
Family preservation services. Social workers practicing in the field of family preservation focus on the
early identification of families at risk of removal of a child and the implementation of concrete services
to help prevent that outcome. In reality, however, family preservation services and intervention are often
reactive rather than preventive and do not occur until a crisis increases the possibility that a child will be
removed. This work involves case management, counseling, and skill building to enrich and strengthen
the family and keep the family structure intact.
Family foster care. If removal of the child for safety and well-being becomes necessary, one out-of-home
placement option is family foster care. Immediate and extended family members are typically assessed as
a first option. The second option is frequently family foster care, where children are cared for in a family
setting by a certified foster care family. Although designed as a temporary form of placement, family
foster care becomes a permanent status for many children, for a variety of reasons. It is also not unusual
for children to be moved from one foster care family to another. With advanced training, some family
foster care providers earn a special designation as treatment or therapeutic foster care placements. Social

250

workers often work directly with children in family foster care, families of children in foster care, and
foster care providers.
Family reunification services. When children are placed outside of the home, family reunification is the
first consideration and is oftentimes viewed as the most desired outcome for children and youth. It is
not an easy path, however. Although parents may articulate love for their children and want to be with
them, parents with children in out-of-home placement struggle to become capable of caring for their
children full time. Social workers employed in family reunification services work with children in
placement and their families, with the goal of successfully reconnecting them. This process often
requires parents to make significant improvements in their personal growth, parenting skills, financial
commitment, and interpersonal functioning. Family reunification must also deal with the trauma
children experience before being removed from the home and while going through the reunification
process. Advocating for the rights of children during reunification processes is another social worker
responsibility.
Adoption services. Adoption is the permanent rendering of legal and parental rights by a child’s birth
parents to adoptive parents. Social workers promote adoption, seek prospective adoptive parents, screen
adoptive parents, make arrangements for adoption, help choose the adoptive parents, assist adoptive
parents in developing a new family, and help birth parents create a better life for their children and
themselves. Some social workers focus on special needs adoptions with children facing unique
conditions, which could include physical, mental, and/or emotional challenges. Adoptions typically take
place through stepparent adoptions, independent adoptions (through attorneys, independent of
agencies), agency adoptions (overseen by an agency), and intercountry adoptions (of foreign-born
children). In each of these types of adoption, the needs and rights of children are the foremost concern.
Residential care. The history of residential care for children in the United States can be traced back to
the establishment of orphanages, which were designed to provide for the basic needs of children who
had lost parents through death, disability, or abandonment. Interestingly, some current therapeutic
group care facilities for children provide residential services in dwellings originally built as orphanages.
However, today’s contemporary residential group care facilities for children are treatment based,
meaning that they are made available to some children and youth who need structure and stabilization
in a nonfamily group setting. In recent years and for a variety of reasons—including lower cost and
better therapeutic outcomes—residential group treatment services have given way to family-centered
outpatient and family foster care. Social workers in group residential centers engage in treatment
planning and implementation as well as aftercare planning and activities.
Independent living services. An appreciable number of adolescents, many of whom are teenagers “aging
out” of family foster care services (i.e., reaching the age of 18), are in need of independent living services.
Social workers help these teenagers become independent by providing a range of services and promoting
skills and abilities needed in adulthood. Support is often provided through collaborative efforts among
foster parents, biological parents, and various service providers. Independent living services include
transitional supervised living, group housing, scholarships, employment counseling, relationship
building (with family members and friends), and connecting with needed resources. A special-interest
consideration is helping these older children develop and maintain constructive relationships with

251

biological and foster family members.
Intensive treatment. Social workers perform a variety of intervention services (specific types of therapy
and counseling) that are classified as intensive treatment. Intensive treatment usually requires an
appreciable time commitment and many resources during a condensed time; so social workers who
operate in this specialty generally have smaller caseloads. Investing in intensive treatment with clients
during crucial times in their lives is often more economical and effective than residential treatment.

Social Policy and Legislation Supporting Child and Family Services

In the United States, services to children and families are typically mandated and shaped by myriad state and
federal policies and laws. Funding for children and family services is equally complex and relies on a
combination of federal, state, and county or city monies, as well as insurance reimbursements and privately
paid fees. To complicate matters, legislators are known to pass laws requiring children and family services
without providing the necessary resources. Under these circumstances, it is understandable that the availability
of quality services and programs for children and families can differ appreciably across state, county, and
municipal boundaries.

Historically, the federal government has passed a number of laws to promote child and family welfare (see
Exhibit 6.2). For example, the National School Lunch Program, Farm Bill, Supplemental Social Insurance,
and Personal Responsibility and Work Opportunity Reconciliation Act established sweeping programs
providing needy children and families with food and financial and health care benefits.

Other legislation listed in Exhibit 6.2 has had a narrower focus, such as the Education for All Handicapped
Children Act and the Runaway, Homeless, and Missing Children Protection Act. Without these specialized
intervention programs, however, vulnerable youth and their caregivers would suffer considerable deprivation
and struggle with everyday needs.

An appreciable amount of time and effort is required to advocate for the passage of federal and state laws
promoting child and family welfare. Countless groups and organizations, and hours of persuasion, were
required to bring these laws to fruition. Yet gaps in service delivery for effective intervention and treatment of
children continue to exist in the United States—for example, affordable day care and early intervention
services to help prevent removal of children from their families (Pecora, Whittaker, Maluccio, Barth, &
DePanfilis, 2009). Children have suffered as a result of underfunding, and the federal funds that are provided
tend to be allocated to placement services instead of being allowed to flow to the family support services
preferred by many states (Pecora et al., 2009). The lack of coherent funding for early intervention and family
support services seems counterproductive to many social workers who are attempting to preserve families and
keep children living at home.

Independent living services offer teens opportunities to learn how to support themselves.

252

Source: iStock Photo / HASLOO

Exhibit 6.2 Noteworthy Legislation Concerning Child and Family Welfare

Public Attitudes Toward Services for Children and Families

Public support for child and family services is frequently mixed. It depends on people’s belief systems and is
frequently not informed by the perspective of social workers and their clients. For example, social workers
often hear neighbors and friends complain about paying too much in taxes for services to children and families
when “these families should be providing for themselves.” Friends and family members can erroneously and
naively suggest that problems with children do not exist with traditional families, when children are reared by
two married, heterosexual parents. Others may acknowledge the need for social welfare but believe that
recipients should be limited to only those experiencing the direst of circumstances, believing the priority
should be encouraging older youth to get married before having children and for parents to work.

Two distinct viewpoints concerning social welfare programs and services can be articulated:

Institutional or primary view of social welfare: Humans are inherently good but are confronted with
challenging needs (e.g., employment, health care, housing) and circumstances (e.g., unemployment,
illness, divorce, loss of a loved one). Social and economic conditions such as unemployment, recession,
and prohibitive costs for health care may also contribute to human need. Communities and society as a
whole have a responsibility to help people by providing economic and social support services.
Residual or secondary view of social welfare: People, including the poor and downtrodden, should be
responsible for their own lot in life and not expect government intervention. Social welfare programs
should be limited to helping people only in the direst situations and should provide only a safety net—
that is, those services that spare people from perishing. Social safety nets are not designed to assist
people to overcome or move beyond their problems.

253

As a prospective social work student, it may be hard for you to understand the residual view of social welfare.
You may be interested, therefore, in the literature describing the belief systems behind some people’s
disapproval of the Personal Responsibility and Work Opportunity Reconciliation Act, federal legislation
passed in 1996 (Long, 2000). Those beliefs are explained in Exhibit 6.3. Although belief systems for both
individuals and groups change over time, many of these beliefs persist and continue to prevent improvements
in programs and services for families and children.

Time to Think 6.4

What do you and your friends think about child welfare views and legislation? How do you imagine impoverished children and
families would react to these views?

Social Workers’ Attitudes Toward Child and Family Services

Social workers strive to be objective and use scientific inquiry and research to guide their views concerning
child and family legislation and programs. Social workers are particularly interested in the effectiveness of
child welfare laws and service delivery systems in the hope that the services and programs will permanently
enhance and enrich the lives of children and families. Thus, when clients use school lunch programs, food
stamps, Medicaid, and Temporary Assistance for Needy Families but are barely able to survive and unable to
progress beyond their current living circumstances, social workers can share in the clients’ frustrations.
However, social workers realize that service provisions are limited and the ability of clients to move forward
with their lives is influenced and limited by a number of factors, including upbringing, life experiences,
personal motivations, social pressures, and the political environment (Kilty & Meenaghan, 1995).

Social workers use the National Association of Social Workers (NASW) Code of Ethics to ground their
practice. Paramount is the desire to use “knowledge, values, and skills to help people in need and to address
social problems” and to “treat each person in a caring and respectful fashion, mindful of individual differences
and cultural and ethnic diversity” (NASW, 2018, “Ethical Principles”). With the NASW Code of Ethics as a
moral compass, social workers stay client centered and resist imposing or reinforcing counterproductive belief
systems concerning children and families. A large part of the social work belief system is a commitment to
client self-determination and the inherent dignity and worth of each person and each family.

Exhibit 6.3 Beliefs Shaping Negative Attitudes Toward the Personal Responsibility and Work
Opportunity Reconciliation Act of 1996

254

Source: Adapted from Long (2000, pp. 63–64).

Time to Think 6.5

It is difficult for people, including helping professionals, to imagine themselves in a client’s situation. Do you know any children who
are at risk of removal from their homes? What kinds of services are available to them or have been implemented? Would it be
difficult and stigmatizing for children and family members to partake of these services?

255

Social Work in Schools

In the United States, all children are required to participate in education. Thus, schools have been a long-
standing venue for identifying and addressing the needs of impoverished, neglected, and abused children.
School social workers emerged in U.S. schools in eastern cities (e.g., New York and Boston) toward the
beginning of the 20th century, both to address student needs and to promote quality educational experiences.
From the very beginning, school social workers were challenged with issues of racism, sexism, and social class
(Joseph, Slovak, & Broussard, 2010), and many of those issues persist in contemporary school systems. Of
particular note are the ways racial and ethnic discrimination has degraded educational opportunity for
minority populations (Joseph et al., 2010).

Many helping professionals would argue that much of front line social work with children and families occurs
in or in relationship to schools. However, the specific roles and activities of social workers and the school
social workers vary in each school and organizational setting. School social workers practice in both primary
and secondary school systems. They work with teachers, administrators, school counselors, community
officials, agencies, and parents and children. A primary task is to promote and advocate for quality educational
programs, outcomes, and experiences, and the well-being of students. Social workers assess the needs of
children and participate in recommending and securing services for schoolchildren and their families
(Constable, 2009).

It is understood that, for students to function effectively at school, it is important to address their needs at
home (e.g., their physical and mental health, family stability, safety, nutrition, and sleep) and at school
(including instruction, physical setting, curriculum, teacher–student relationships, and student relations).
School social workers find themselves employed in an organizational environment advocating for
interventions, programs, services, and organizational change that support the best interests of their primary
client population—the students. In addition to counseling students, school social workers intervene with
family members, school officials, lawmakers, and community leaders to identify ways to enrich social
conditions and circumstances for student success.

With regard to professional qualifications, school social work has become an increasingly specialized area of
practice in the United States. National and state policy has promoted the credentialing of professionals in
school settings, which has led in turn to certification, licensure, and advanced training for school social
workers (Constable & Alvarez, 2006).

256

Challenges Facing School Social Workers

School social workers become involved with students as a result of a variety of problems and behavioral
manifestations, such as acting out in the classroom (verbally and physically), truancy, poor grades,
interpersonal conflicts, a lack of personal hygiene, health issues (e.g., headaches, frequent illnesses), and
inappropriate appearance (e.g., unkempt hair, dirty clothes).

Many factors are salient to problems with student performance and behavior. It is not unusual for school
principals and teachers to point out student responsibility as well as the influence of family members and the
home environment on school performance. Conversely, students and parents often allude to the importance of
teachers, peers, and curricular matters in relation to student behavior. Frequently, students’ problems are
complex and involve many factors—not easily pinned on a single source.

Unfortunately, when school systems face fiscal challenges, school social work positions often fall victim to
reductions or elimination. In these instances, student learning and well-being become compromised as various
student needs (e.g., stable home life, mental health issues, sleep deprivation, food insecurity, and medical
problems) go unaddressed and unmet.

Violence and Bullying

In the United States, children are exposed to multiple forms of violence. Modern media and entertainment
expose children to guns, shootings, killing, interpersonal violence, verbal abuse, aggressive behaviors, and
bullying. Children witness violence at home, between adults, and when adults inflict violence on children. In
some communities, exposure to violence—punching, fighting, shootings, threat of physical harm, robbery,
muggings, and use of weapons—is common and readily visible to children. Violent acts in schools include
bullying, punching, fighting, homicides, and suicides.

Bullying is a form of aggression against others that is prevalent in elementary and middle schools. It involves
physical, verbal, or psychological attacks, including harassment and intimidation, against weaker children or
children who cannot defend themselves (Laursen, 2011, p. 4). Bullying can take the form of group bullying,
racial bullying, cyberbullying, or gay bullying—among others.

Previous research in the United States indicated that up to 41% of students had been involved in bullying at
school, either as a victim (23%) or as a bully (8%), or as both bully and victim (9%) (Bradshaw, Sawyer, &
O’Brennan, 2007). However, much of bullying behavior goes unreported, and when considering cyberbullying
behavior, these percentages are likely underestimated.

Research indicates that, psychologically,

bully/victims were most likely to display internalizing symptoms, problems in peer relationships, and
have poorer perceptions of the school environment. Both frequent bullies and bully/victims
displayed aggressive-impulsive behavior and endorsed retaliatory attitudes. High-school students

257

frequently involved in bullying tended to display the greatest risk for internalizing problems, but less
risk for aggressive impulsivity. (O’Brennan, Bradshaw, & Sawyer, 2009, p. 100)

Social workers need to remember that student bullying takes place in a social context. To effectively prevent
and intervene with bullying, the individuals involved and the social context in which bullying occurs must
both be addressed (Bradshaw & Johnson, 2011; Laursen, 2011). A healthy learning environment must include
caring relationships and a safe and secure educational setting. Seven habits for professionals who are trying to
construct caring relationships with young people when addressing bullying are these: Be respectful,
demonstrate empathy, be credible, actively listen, affirm positive behaviors, act as a positive role model
concerning accountability, and take time to place youth as a priority (Laursen, 2011, p. 9).

It is important to note that school age children often struggle with gender and sexual identity, which is a
source of bullying in schools. For example, bullies have been known to tease, verbally abuse, ridicule, and beat
classmates on the basis of gender expression, a child’s outward appearance (e.g., via clothing, hair style,
makeup, jewelry, and body expression). Bullying behavior can also involve destructive actions levied toward
student use of bathrooms on the basis of gender identity, one’s internal sense of identity as a gendered person.
In 2017, National Geographic dedicated a special issue (Vol. 231, No. 1) of its magazine to promote a
thorough examination and understanding of contemporary gender issues, terminology, and definitions. This
publication is very useful for advancing public and professional education and discourse about gender and
sexual identity issues in relationship to children.

Economically Disadvantaged and Homeless Students

Poverty and homelessness constitute challenging barriers confronting school social workers. Whether they are
in dire economic straits and homeless as a result of unemployment, underemployment, or not being
employable, poverty stricken and homeless families are highly transient, frequently changing home addresses
and school systems. Although the homeless often find temporary housing in shelters, they are vulnerable and
can easily find themselves out on the street at any time. Mental health and substance issues can also be
contributing factors to instability. At a very basic level, economically disadvantaged and homeless children
often arrive at school hungry and sleepy. These students are at considerable risk of poor school attendance and
performance.

Parents and children also experience daily risk and considerable stress when everyday necessities and a
dwelling become questionable. As a consequence, children adopt maladaptive behaviors, experience social and
cognitive setbacks, and are prone to poor grades and high dropout rates (Groton, Teasley, & Canfield, 2013,
p. 38). These are some of the reasons why school social workers and social work interventions focusing on the
student’s overall situation (family, teachers, living circumstances, school policies, community safety) are vital
to student success.

An important piece of national legislation focusing on the needs of homeless children and families is the
McKinney-Vento Homeless Assistance Act. The act’s mandates for homeless students include the following

258

(Groton et al., 2013, p. 39):

Streamlining enrollment procedures for homeless children so they can start school in a new place
without all their previous school records, documentation of residency, and immunization records
Employing homeless liaisons to advocate for the rights of homeless students
Subsidizing homeless students’ full participation in school events

Students With Physical and Mental Challenges

Knowing that language shapes social and personal realities and images, social workers are cautious and
intentional with the use of words and language. In social work practice, care is taken not to label children with
physical and mental challenges as being “disabled” or having a “handicap.” Instead, social workers try to be
positive and focus on strengths when referring to and working with children who have a physical or mental
challenge.

Teen girls often feel the consequences of pregnancy more than the father.

Source: iStock Photo / funky-data

Children with physical challenges face unique hurdles in schools, including limits on their participation in
activities, being made to feel different through the use of accommodations, being stereotyped, and being
bullied. Schoolchildren with physical challenges have a right to be treated fairly, given their individual
strengths and needs. Optimally, fairness is achieved when students and their parents participate in school
decision-making processes that promote an appropriate and beneficial educational experience.

Children with mental challenges constitute a major public health issue. Childhood mental disorder (CMD) is
a general term that includes all mental disorders that begin and can be diagnosed in childhood, such as
Asperger’s syndrome and developmental delays. CMDs are often identified during the school years and in
conjunction with professionals in school systems. Estimates suggest that between 13% and 20% of children in
the United States experience a CMD and that nearly $247 billion is spent each year on CMDs (National
Research Council and Institute of Medicine, 2009).

A major law advancing the interest of students with physical and mental challenges is the Individuals with
Disabilities Education Improvement Act, reauthorized in 2004. This act promotes the rights of challenged
students in a number of realms, including the following (Massat, Essex, Hare, & Rome, 2009, pp. 124–125):

Using peer-reviewed research and scientifically based behavioral and instructional techniques for

259

physically and mentally challenged students
Expanding the definition of parent to include foster parents and nonparent caregivers
Emphasizing a student’s right to a free public education in the “least restrictive environment,” in
conjunction with a student’s Individualized Education Program
Bolstering the educational expectations and requirements of teachers and other educational staff

Teen Pregnancy

Teen pregnancy, sometimes referred to as “children having children,” is frequently cited by politicians, social
scientists, and social service professionals as one of the nation’s most serious social problems. Historically,
people have objected to teen pregnancy on a values-oriented, moral basis involving a lack of responsibility and
indulgence in premarital or casual sex. However, for many adolescent students, the everyday functional
drawbacks of teen pregnancy and parenthood are as devastating as or more devastating than moral judgments.

Although teen pregnancy involves both a male and an adolescent female, the consequences of pregnancy for
teenage girls are often far greater than for their male counterparts. Fathers may deny or contest paternity, or
they may take responsibility for fathering and assist in caring and providing for their children. But if the father
is also a teenager and a student, he may have very limited knowledge and resources for effective parenting.
And it is often very difficult to legally mandate and enforce paternal responsibilities for fathers who have no
employment or other resources.

Current Trends

260

Best Buddies International
Children and adults benefit when they are surrounded by caring, loving, and supportive people and are provided with well-designed
services. Best Buddies International is a global volunteer movement promoting opportunities and healthy relationships for people
with intellectual and developmental challenges. Volunteers provide friendship, employment, and leadership opportunities for
members of this population group. Best Buddies International programs foster one-to-one friendships between adults and between
students. For additional information about Best Buddies International, visit the organization’s website (www.bestbuddies.org).

To an extent, Best Buddies International is a worldwide adult program similar to local Big Brother and Big Sister programs—where
boys are matched with positive male role models and girls are paired with positive female role models. These types of programs offer
people social–emotional support, constructive relationships, and opportunities for developing interpersonal skills with others. Social
workers have traditionally been employed in these venues and often have served in leadership roles. When working with adults with
challenges and child and adolescent populations, social workers often refer parents and clients to these types of organizations.

What is your initial reaction to organizations such as Best Buddies International that heavily rely on volunteers? Consider the importance of
professional oversight and developing a sound application and background check system for volunteers. Would you ever become a Best Buddy?
Why or why not? Discuss with classmates and friends the level of commitment required to serve as a volunteer with such programs.

For teen mothers, the pregnancy is a medical issue. Prenatal care also interrupts school attendance and
extracurricular participation. Motherhood requires attention to child care, is a barrier to gaining experience
and tenure in the labor force, and requires a reexamination of living circumstances. Reliance on parents,
siblings, and extended family members for housing, food, clothing, and child care is common. But even with
this help, teen mothers may not be able to continue in school.

School social workers and agency-based social workers assist teenagers and their families with transitions
during this difficult time. They may explore with teen mothers enrolling in public assistance, such as
Temporary Assistance for Needy Families and Medicaid, to provide minimal income and address medical
needs. In addition to helping teen mothers with immediate needs for nutrition, clothing, furniture, shelter,
and child care, social workers also focus mothers’ attention on long-term issues involving continued education,
father involvement, child support, transportation, affordable and safe housing, and employment.

261

Improvements in Education to Help Parents and Children

In the United States, public school systems are highly dependent on state and local funding for educational
programming and services. This decentralized approach to supporting education lends itself to inequities,
particularly on the basis of socioeconomic status. Students living in affluent areas are able to attend highly
sought-after primary and secondary schools. Students living in economically disadvantaged areas,
disproportionately from racial and ethnic minorities, are relegated to struggling school systems. Those school
systems typically fall short in preparing students to work in a global economy (Heiner, 2013). Middle-class
and wealthy children, in contrast, attend better schools that help them prepare for better jobs. From this
perspective, schools function to maintain class membership and distinctions.

Any real estate agent will tell you that one of the very first questions buyers will ask when looking for a
desirable neighborhood is, “Where are the best public schools?” Even if the buyer does not have or expect to
have children, purchasing in an area with an excellent school system protects property and resale values. Yet
many Americans, especially the poor and disenfranchised, can’t afford to live where they would like their
children to attend school.

To improve education, social workers not only promote quality academic experiences inside schools but also
advocate for laws, policies, funding, and programs to help ensure that students receive a quality education
regardless of school location. The commitment people make when entering social work as a profession is both
to help people in need and to address the social problems contributing to their difficulties. Advocating for
quality educational systems and reducing inequities in education are excellent examples of how social workers
can work toward larger-scale changes.

262

Diversity and Family and Child Welfare

People often conceptualize diversity and associated types of oppression in terms of a form of diversity familiar
to themselves. For example, teenagers often dream about what they would do if only they were old enough to
vote, own property, drink alcohol, marry, and make legal decisions for themselves. They are focused on age
discrimination. However, understanding how different forms of diversity impact individuals, groups,
communities, and societies is vital in social work practice. Let’s stretch our thinking beyond any personal form
of diversity to examine how selected forms of diversity relate to child and family welfare and services.

Age. Developmentally, young children are forming their personalities and learning about what is right
and wrong. Children prosper through the presence of a stable family and positive adult and parental role
models. Young children are especially vulnerable and dependent on family members for affection and
basic needs, including food, shelter, clothes, medical attention, and nutrition. But they have limited
rights and ability to advocate for themselves, especially when compared with parents and school officials.
Class. Children living in economically challenged circumstances struggle with obtaining a safe living
environment, quality child care or schooling, proper nutrition, suitable clothing, reliable transportation,
and other basics. As for their families, unemployment, underemployment, and homelessness are
common disruptive factors. Although many of the problems facing children and families transcend their
socioeconomic status, having access to resources through social service agencies and the ability to secure
needed help ameliorates the disadvantages of lower-class living.
Ethnicity. Across the United States, many families identify themselves by ethnicity and enjoy strong
bonds based on common ancestry, homeland, language, religion, and dialect. Members of a particular
ethnic group also share values and expectations about individual behavior. Some ethnic groups believe in
individual responsibility and reliance on help from within the ethnic group; they tend to rebuff helping
professionals and social service programs. Members of other ethnic groups recognize the value of child
and welfare services but prefer to receive help from organizations and professionals aligned with their
cultural heritage. As an example of how cultural values can shape attitudes about issues such as work and
social welfare, many Latinos possess a strong work ethic but often lack education and job skills to secure
nonmenial employment. As a consequence, Latino population groups can struggle with the idea that
people with lower-wage employment can simply work their way out of poverty (Acevedo, 2005).

Social Work in Action

263

Pamela Facilitates Adoption for Gay and Lesbian Parents
Pamela Howard is a BSW-level social worker employed at a large, urban children’s advocacy center (CAC). She works in adoption
services, especially for gay and lesbian parents. Primarily as a result of her practice experience, Pamela has an enriched sense of how
members of lesbian and gay families can be stigmatized. She knows that adoptive gay and lesbian parents worry about their ability to
gain legal custody and about their risk of losing it. There is a general lack of recognition of their parenting abilities, responsibilities,
and rights.

In Pamela’s state, gays and lesbians are allowed to form civil unions but not to marry. The legal ramifications for adoption by
unmarried gay and lesbian couples are even greater than for married gay and lesbian couples. Many of Pamela’s clients are concerned
about their ability to adopt in the first place, as well as the limitations of their status in regard to custody, health care benefits, and
educational rights and opportunities for their adopted children.

The CAC where Pamela works has an interdisciplinary and interprofessional orientation. Pamela has been able to work closely with
a team of social workers, nurses, counselors, and other professionals to provide educational and supportive services related to the legal
system, health care insurance, employers, and schools. One of Pamela’s favorite colleagues at the CAC is an attorney, who has been a
wealth of information for gay and lesbian adoptive parents. As a result of Pamela’s interaction with this attorney, she is now
entertaining the possibility of continuing her professional education in a program where she could simultaneously earn an MSW and
a law degree.

Take some time to contemplate the host of professions (attorney, psychologist, public health official, nurse, counselor, and so on) that interface
with social work and how each profession differs. Which professions focus on interpersonal, one-on-one intervention with children and
families? Which professions focus on advocacy, policy development, and system-level change? Which types of helping appeal to you?

Families may represent several types of diversity.

Source: ©iStockphoto.com/funky-data

Race. Despite decades of advocacy for desegregation, school systems in the United States remain
segregated on the basis of race and social–economic status. Racial desegregation laws and U.S. Supreme
Court decisions from the 1960s mandated the end of racially segregated schools, but the phenomenon of
white flight has rendered those decisions moot in many U.S. cities. In the early years of desegregation,
Caucasian families moved from the city to the suburbs to escape desegregated schools and enrolled their
children in better-resourced public or private schools. Minority families, disproportionately poor, came
to dominate urban neighborhoods. For example, many African American families live in poorer urban
neighborhoods and consequently must send their children to less-desirable public schools. The inability
for all students to attend schools characterized by quality instruction, extracurricular activities, and
integrative support with family members is one form of structural discrimination and institutional
racism that persists in the United States.
Gender. In the United States, women continue to be commonly viewed as the primary caretakers of

264

children. When marital discord or family disruption takes place, mothers often assume custodial
responsibilities for the children. Although state laws set standards for parental financial responsibilities
and visitation with children, enforcement of legal obligations can be difficult. For example, it is not
unusual for the noncustodial parent, often the father, to leave the state, be delinquent on child support,
and seek undocumented forms of income. Also, women have been threatened by the fathers of their
children not to pursue paternity or court-ordered child support. Women face unique and demanding
situations, and they rely on child and family services for support in ways that often differ from those of
their male counterparts.
Sexual orientation. Marital and parental rights for gays and lesbians are currently grounded in state law
and amidst change. In part, this is a social justice issue involving the ability of parents and children to be
treated the same regardless of the parents’ sexual orientation. However, this kind of legal limbo leaves
many gay and lesbian parents with uncertainty and doubt. For example, what are the ramifications for
parental and family rights if the family has to move from one state that protects their rights to another
state that does not? If the parents divorce, separate, or split up, how do their parental rights differ from
those of their heterosexual counterparts? With regard to everyday rules and practices, will school
officials, employers, and health care providers treat gay and lesbian parents—and their children—with
the same respect and dignity as they do heterosexual families?
Intersections of diversity. It is not unusual for parents and family members to represent several types of
diversity. For example, teenage mothers with little education, financial resources, or experience in the
labor force are particularly vulnerable to poverty and a lack of economic opportunity. The cost of day
care for a single, young mother is prohibitive, particularly when she may be qualified only for low-
paying employment with irregular or unusual working hours. Young mothers from racial and ethnic
minorities face the additional risk that prospective employers might discriminate on the basis of not only
age but also race or ethnicity.

265

Advocacy on Behalf of Families and Children

Federal interest in children arrived on the heels of a variety of social reform initiatives of the late 1960s and
can be traced to the presidency of Richard M. Nixon. In response to recommendations from the Joint
Commission on Mental Health of Children and the 1970 White House Conference on Children, a National
Center on Child Advocacy was established (McGowan, 1978). However, due to limited resources, shifting
federal priorities, and mounting interest in the creation of a new National Center on Child Abuse, the
National Center on Child Advocacy was never fully realized.

During the 1970s, recognition of the need for child advocacy led to strengthening of the services and
programs serving children and families. The child welfare advocacy movement advanced the following major
themes (McGowan, 1978, p. 277):

Child development is influenced by interaction with families and transactions with other social systems
(e.g., schools, child-care providers, courts, medical providers, and court systems).
Society has a responsibility for and obligation to children.
Child and family services are a matter of right and entitlement.
Children have rights in relationship to the social systems affecting them.

As with many social problems and issues, recognition of need and responsibility at the institutional, systemic
level does not necessarily or immediately translate into social change or large-scale dedication of resources.
The conceptual shift from rescuing and saving children from unfit parents to the development of
comprehensive, integrated child and family services that support the healthy physical and emotional
development of children and families has been decades in the making.

266

Current Trends in Advocacy for Child and Family Services

The contemporary social worker is moving away from viewing advocacy for children and families as mainly a
social work responsibility and toward viewing it in terms of interdisciplinary collaboration. In recent years,
children’s advocacy centers (CACs) have emerged. CACs typically provide a broad range of services for
children and families and are known for their interdisciplinary and child-focused approaches. CACs often
employ professionals from law enforcement, social services, and mental health, offering a unified, centralized
agency for providing services and programming for children and their families (Wolfteich & Loggins, 2007, p.
334).

It appears that CACs can improve investigations of child abuse (Wolfteich & Loggins, 2007). However, the
effectiveness of CACs for addressing other child and family needs and advocating for needed services remains
unclear, especially in the realms of early intervention and child maltreatment. People who provide services to
children and families are hoping that interagency collaboration and interdisciplinary teams, as employed in
CACs, will broaden the reach and strength of a variety of advocacy initiatives.

267

Dynamic Advocacy and Family and Child Welfare

When advocacy involves children, who have limited rights, it continues to be relevant and important for social
workers to advocate with, not simply for, their clients. For social workers involved in child and family services,
the concept of “best interest of the child” is a primary consideration. At the most basic level, children’s needs
for healthy development and maturation are the priority. But beyond that, the needs of children are often
complex, multidimensional, and immersed in family problems and needs.

Determining the best interest of the child can be challenging for other reasons as well. Advocacy with children
is centered on the question, “What do you want?” (Hoefer, 2012). However, children express their desires and
needs through words, action, and inaction. Their cries for help can take a number of forms (e.g., acting out,
bed-wetting, withdrawal, pleading, frightened facial expressions, clinginess, physical distance). Because the
actions of children are open to interpretation, social workers must take care to ensure that they consider the
individual before them and not make assumptions based on stereotypes about children (Boylan & Dalrymple,
2011, p. 24).

Economic and Social Justice

What constitutes just services and a just life for children? All children deserve the potential for health, well-
being, and a good quality of life, as well as the ability to mature and develop in culturally appropriate ways.
Children, especially young children, struggle intensely with their limited ability to exert power and impact
decisions affecting their lives. Much of the history of child welfare has focused on saving children from
maltreatment and abusive and neglectful circumstances, not empowering children to effect change. Children
have been seen as dependents, without adult rights, and their perspectives have not typically been valued in
policy and legislative development.

Social workers have challenged these premises and supported child advocacy initiatives in a number of realms.
Organizationally, guardian ad litem programs appoint individuals to speak and advocate on behalf of children
in court systems. Similarly, school social workers advocate for changes in policies, programs, and personnel in
educational systems to benefit students.

Social workers can solicit the meaningful participation of children in decision making and educational
processes in a number of ways:

Conducting interviews and surveys designed to gain children’s insight into issues, problems, and
solutions
Joining a child advisory or advocacy council
Speaking at public forums and professional workshops about the needs and interests of children
Organizing clubs to support children in need and at risk, and disseminating information
Creating art, films, and music to express children’s needs or working with the children themselves to
produce such art, films, and music

268

Supportive Environment

The plight of many children and families is grounded in social–economic circumstances and conditions. In the
United States, the affordability of rent or the ability to make a house payment determines where you live. In
turn, the location of your dwelling impacts your access to extended family members, employment, public
transportation, health care, education, day care, social services, shopping, and recreation.

Exposure to crime and pollution are also based on place of residency. Social workers and clients partner with
government and law enforcement officials and local businesses to advocate for community safety watches and
groups, as well as entities dedicated to effective air, water, and waste-control systems. People living and
working in impoverished neighborhoods share common interests and bonds to reduce crime and maintain a
healthy and safe environment.

Human Needs and Rights

Through their education and training in the area of human behavior and the social environment, social
workers acquire the theoretical foundations and knowledge they need to analyze human development from
birth through childhood, adolescence, adulthood, and older age. This foundation is necessary for social
workers to understand and facilitate both smaller, micro-oriented changes and large-scale, macro-oriented
changes throughout various stages of human development.

When advocating for change with specific populations, social workers must be keenly abreast of the unique
needs, limitations, and rights associated with various age groups. For example, in the case of early-childhood
intensive treatment programs, it is unrealistic to believe that young children can verbalize and specifically ask
for certain types of services. Children deserve the right to successful childhood development, and it is the
social worker’s professional and ethical responsibility to advocate for and pursue social change for one of
society’s most vulnerable population groups.

Political Access

Support for children and family services, as with many forms of social services, is a political issue based on
dominant belief systems. For example, some politicians oppose social programs and services in an effort to
demonstrate fiscal responsibility, reduce government intervention in the lives of people, and support
traditional families and family self-sufficiency. Other politicians recognize the vulnerabilities and complexities
associated with children and families in a complex and changing society. They often couch their support for
the funding of programs and services for children and families in terms of promoting compassion for and
protection of children and strengthening the family unit, regardless of the family structure. It should be noted
that support for children and family services cuts across party affiliation.

Provision of services for children and families is dependent on funding and resources. One way social workers
may advocate for more funding and resources is by becoming more involved in the political process—whether
campaigning for politicians, social service funding, levies, or legislation to protect children. In the process,

269

social workers may align themselves with political figures, parties, and associations to educate people about
and promote effective services and programs for children and families. Social workers have also been elected to
political offices in local and state government as well as the U.S. Senate and House of Representatives, where
they can become directly involved in crafting policies favorable to children and families.

270

Your Career in Family and Child Welfare

When working with children and families, social workers may be protective service workers, information and
referral specialists, therapists, or program professionals. In each of these roles, social workers collect
information and rely on data to inform best practices. Research skills are involved in a number of other social
work roles as well:

Program evaluators use their research abilities to provide information to help make decisions about the
aspects of service programs that work best for children and families, and the ones that need to be
adjusted.
Advocates and educators collect and use data to educate the public, politicians, administrators, and other
decision makers concerning the experiences and problems of children and families.
Community organizers collect information and gather and rally consumers of services, professionals, and
community members to promote changes in policies, practices, and laws to address the needs of children
and families.

Each of these roles depends on the ability to use qualitative and quantitative research skills to collect and
analyze information:

Qualitative research highlights data that is descriptive in nature and not quantified into numbers. Data is
gathered through methods such as case studies, focus groups, observation, interviews, and archival
research. Generally, qualitative research focuses on small groups of people to understand a phenomenon
or social unit in depth.
Quantitative research involves collecting from a larger group of people data about social behaviors,
phenomena, programs, and social units. Generally, it often relies on surveys and checklists, and it
generates data that is converted into numbers and analyzed statistically.

Time to Think 6.6

Think about a social work topic that is of particular interest to you. What kind of research, qualitative or quantitative, might be the
most effective way of studying that issue?

How might you use qualitative and quantitative research in fields such as public administration, community relations, politics,
management, or other social work–related careers?

Summary

There is no trust more sacred than the one the world holds with children. There is no duty more important than ensuring that their
rights are respected, that their welfare is protected, that their lives are free from fear and want and that they can grow up in peace.

Kofi Annan

The people of the United States are in the midst of a debate about what constitutes marriage and a family. Simply consider the
debate about the rights of gays and lesbians to marry and assume legal responsibilities for each other and their children. Regardless of
the outcome of these debates, the U.S. family has changed, and social workers practice with families in need, no matter their

271

composition or circumstances. Child and family services should be viewed as a major element for helping maintain a social fabric
that has always heavily relied on individuals committed to family and mutual support.

Social workers play an important role in assisting couples, parents, and children to adapt to contemporary demands concerning work,
child rearing, relationship building, and self-fulfillment. Social workers also advocate for social legislation, policies, and social welfare
programs to address the rights and needs of children and family members. In practice, social workers both assist with the day-to-day
trials and tribulations of family life and identify ways to protect and advance the rights of children and families.

272

Top 10 Key Concepts

child maltreatment
child protective services
child welfare
domestic violence
extended family
family
kinship
nuclear family
qualitative research
quantitative research

273

Discussion Questions
1. For social workers, what constitutes a family in the United States today? How does that definition align with your personal values

and beliefs? How has the definition of family changed over the past four decades?
2. What attributes are needed to be a social worker in child protective services and to deal with instances of child abuse and neglect?
3. Why do parents have more rights than children do? Is this simply a matter of convention and tradition? Why or why not? Are

there times when the rights of parents should supersede the rights of children? If so, when and how? Why are parents required to
participate in intervention programs for the benefit of their children? To what degree is this requirement political? To what degree
is it practical?

4. Why is advocacy such an important responsibility for social workers engaged in child and family services?

274

Exercises
1. Given the multiple definitions of family in contemporary society, determine whether gay and lesbian parents should have rights

that are comparable to the rights of heterosexual parents. Base your conclusions on statistics from your state or locale describing
the outcomes for children raised by same-sex parents, single parents, grandparents as parents, foster parents, and residential care
for children.

2. On the Internet, identify a child welfare BSW or MSW program near you. How appealing is the program? Does the program
sponsor an open house or any opportunities to talk with or contact the program coordinator, students, or recent graduates?

3. In a private setting with friends or family members, broach the topic of government spending for services and programs to protect
children. Identify belief systems that support their opinions. Are their views surprising to you? What are the probable sources of
their belief systems and thoughts?

4. Consider volunteering at a residential program for children. Research the type of commitment you would be making. Does it
involve a criminal background check, references, and drug screening? Ascertain if and how services for families and parents are
integrated with the residential program.

5. Research your local child protective services agency. Who provides and advocates for such services? For example, does your local
child protective services agency hire licensed helping professionals (social workers and counselors), or are these positions filled by
nonprofessionals? If the latter, in what areas of providing and advocating for services to children and families do you think the
nonprofessionals would need to improve their skills?

6. Visit a family court and determine who appears to be looking out for the best interests of children. Is a guardian ad litem present?
How are the views and interests of parents placed before the court?

Online Resources

Child Advocates, Inc. (www.childadvocates.org/?gclid=CK-a07XGybECFUgDQAodWgsAsg): Describes how court-
appointed volunteers advocate for children and child protection
The Child Welfare League of America (www.cwla.org): Provides a description of this coalition of private and public agencies
that serves vulnerable children and families through a variety of publications and services, including advocacy
eHow money website (www.ehow.com/how_4685372_becoming-child-protection-social-worker.html): Examines becoming
a child protection social worker
National Association of Social Workers (www.socialworkers.org/advocacy/updates/2003/081204a.asp): Provides a fact sheet
on Title IV-E child welfare training program
South Dakota Department of Social Services and Division of Child Protection Services (dss.sd.gov/cps): Describes state
social and child protective services
UNICEF (www.unicefusa.org/assets/pdf/Toolkit_End-Trafficking_Oct_2012.pdf): Informs and guides professionals on
how to fight human trafficking

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

275

Chapter 7: Health Care and Health Challenges

Source: ©iStockphoto.com/sshepard

276

Learning Objectives
After reading this chapter, you will be able to

1. Describe health challenges and the American health care system.
2. Recognize health disparities, stigma, and ethical dilemmas with health care.
3. Evaluate the current state of health care policy in the United States.
4. Articulate trends in health care.
5. Identify health care settings that employ social workers and the roles of social workers in those settings.

Gayle Practices Social Work in a Teaching Hospital

Gayle serves as a health social worker on the neurology floor of a fast-paced teaching hospital. She is an appreciated member of the
multidisciplinary team because she efficiently assesses new patients’ needs and their family dynamics. Gayle also quickly completes
substantive chart documentation so appropriate and timely discharge planning can occur. Over the years, Gayle’s community
networking skills, policy knowledge, and resource savvy have given her the reputation of being the consummate health social work
professional and team player.

Gayle is a highly sought-after field instructor among students who wish to pursue health social work careers. This semester Gayle is
supervising Becky, a student who is required to complete experiential service learning as part of her Introduction to Social Work
class. Becky thinks she, too, may want to work in a health care setting.

During team meetings, Becky observes how Gayle—along with the dietician; speech, occupational, and physical therapists; medical
students; and nurses—contributes important aspects about each patient as the attending physician, Dr. Iqbal, facilitates. The people
discussed during today’s rounds are recovering from strokes (cerebrovascular accidents), sickle cell anemia, accidents that have
resulted in traumatic brain injury, myasthenia gravis, epilepsy, and Lou Gehrig’s disease (also known as ALS—amyotrophic lateral
sclerosis). Becky empathizes with how vulnerable and stressed each patient must feel. As well, she senses the strain and worry felt by
family members and caregivers alike. She is also aware of the complexity of health care systems, and the challenges faced by those
who are either uninsured or not covered by good private insurance.

Becky admires Gayle’s skill set, eclectic theoretical framework, policy knowledge, and life experience. As an MSW-prepared social
worker, Gayle has worked in community and private hospitals, long-term care, home health, rehab, and hospice. Before her position
on the neurology floor, she also worked as a clinical trials social worker with a National Institute of Health–funded community-
based program that conducted clinical trials with people living with HIV/AIDS.

Twenty-first century health care issues and policies are so complex and multidimensional that innovative
responses across professions and at all societal levels are required. Social workers and other health care
providers see how the effects of negative social interactions and stigma affect health and well-being, and they
keep updated on the latest policies, medical practices, and health-related resources. Whether working in
hospitals, hospice, home health, rehab, schools, government agencies, public health, or local community-
based organizations, health social workers (especially the growing numbers of public health social work
professionals) are actively making connections between prevention and intervention from one person to the
entire population and advocating for people who are suffering from diseases and illnesses. Interprofessional
practice is a term often used to reference efforts and activities integrating professional practice across two or
more helping and health care professions.

In response to the politics and economics of America’s dynamic health care system, social workers are required
to have a broad range of knowledge that includes the leading causes of death, new health care concepts and

277

practices, and federal, state, and local policies. The reality is that the health care one receives in the United

States is tied to the insurance industry and government entitlements that may or may not be universally
available. Because of disparities in health care access, service apportionment, and quality, populations such as
the economically vulnerable, undereducated, chronically ill, and older adults need the skills and advocacy of
social workers in the health care arena.

The multifold purpose of this chapter is to explore health challenges and diseases, identify health care system
structures and realities, appreciate expanding roles for health social workers, and gain insight regarding how
particular health care policies and programs affect Americans. Also, because culture is a significant
determinant of health care because it affects how people communicate, cultural factors are considered as they
influence coping with disease and treatment and as they affect patients’ attitudes and beliefs about illness and
health practices (Saca-Hazboun & Glennon, 2011).

278

Health Challenges and the American Health Care System

The U.S. health care system, with all its strengths and shortfalls, is evolving rapidly. Social work advocates
and practitioners, along with the general public and all those who work in the health care system, are in the
process of grappling with the business and ethical realities of health care, political controversies, the practices
of powerful pharmaceutical companies, and the implications of constantly emerging knowledge about the
human body and its care.

Fundamental to these concerns are the definitions of health and illness. According to the World Health
Organization, health is a state of complete physical, mental, and social well-being, and not merely the absence
of disease or infirmity (cited in Barker, 2014, p. 190). In a sense, then, health is a metaphor for well-being. To
be healthy means you are of sound mind and body, integrated and whole. By contrast, illness is a disease or
period of sickness affecting the body or mind. Illness is costly, and health is a precious commodity.

Exhibit 7.1 Leading Causes of Death in the United States

Source: U.S. Census Bureau (2011).

Athletes, occupational and physical therapists, physicians, and nurses—and particularly social workers—all
recognize that achieving good health is a matter of attending to a person’s physical, mental, and social
situation. Further, disease, disability, and death are the result of interconnections between human biology,
lifestyle, environment, and social factors (World Health Organization, 2003). Researchers have considered
why some people engage in health-promoting behaviors and others do not and learned that culture affects
how people perceive health and make decisions (Saca-Hazboun & Glennon, 2011).

When good health is not sustained across a lifetime, as when accidents occur or genetic factors intervene,
illness and perhaps death result. The leading causes of death reported for people residing in the United States,
illustrated in Exhibit 7.1, might surprise some.

279

Time to Think 7.1

Think about your total well-being. Do you believe you are a healthy person overall? How much weekly exercise do you get, and what
kind of food do you eat? Do you need to lose weight, stop addictive smoking, or discontinue excessive binge drinking? How well do
you manage stress and your mental health? Do you have family members and a circle of friends who support you and spend time
with you?

280

Threats to Americans’ Health

Of 17 high-income countries studied by the National Institutes of Health (NIH) in 2013, the United States
had almost the highest prevalence of infant mortality, heart and lung disease, sexually transmitted infections,
adolescent pregnancies, injuries, homicides, and disabilities (Woolf & Aron 2013). Combined, these concerns
put the United States at the bottom of the list for life expectancy. This means that, on average, a male
American can be expected to live about 4 years less than a male in the top-ranked country.

On the other hand, in 1900, average life expectancy in the United States was 47 years. Today, average life
expectancy is more than 77 years, which is an astounding increase of 30 years in the span of a century. Much
of this improvement, especially during the first 50 years of life, has come from changes in lifestyle and living
conditions. Advances in biomedical and sociobehavioral science have also increasingly contributed to life
expectancy. In the past 30 years, almost 6 years of life expectancy gains have come from improvements in the
management of cardiovascular diseases, spearheaded by research funded through the NIH (Xu, Murphy,
Kochanek, & Bastian, 2016).

At least 50 of the improvements in Americans’ health have been attributed to sociobehavioral factors, such as
malleable individual factors (e.g., smoking, poor diet, stress, inactivity, violence, substance use) and social and
health care system factors (e.g., medical errors, gender bias, low health literacy, lack of insurance or access to
health care). Many theories of health have been based on imbalances in the body, in the person, or in social
relationships (Albrecht, 2006). Yet today lifestyle continues to threaten health and longevity in three key ways:
chronic illness, heart disease, and stress.

Chronic Illness

Chronic illness is the personal experience of living with chronic disease, which is a persistent, long-lasting
health condition. The term chronic is usually applied when the course of the disease lasts for more than 3
months, and it can be controlled but not cured.

Chronic illnesses cause about 70% of deaths. Examples of chronic disease include asthma, chronic obstructive
pulmonary disease, diabetes, depression, and heart disease. Chronic diseases are the leading cause of death and
disability in the United States (Johnson & Johnson, n.d.). Exhibit 7.2 shows the proportion of various aspects
of the U.S. health care system used by people with chronic illnesses.

People with chronic diseases often suffer from reduced quality of life. For example, progression of diabetes can
result in amputation of lower limbs, and asthma can limit a person’s ability to exercise and engage in
pleasurable leisure activities.

Many chronic diseases are preventable and can be managed by mitigating risk factors, making lifestyle and
dietary changes when necessary, and following prescribed treatment regimens. However, chronic illness and
disease are greatly influenced by education, environment, employment, and socioeconomic status. Thus,
people least advantaged will continue to experience more than their share of chronic illness. Social workers

281

play vital roles in educating patients who are health illiterate, reinterpreting complicated medical jargon used
by physicians, and connecting people to community resources so healing can continue at home. Social workers
can also play a role in addressing underlying health determinants, a population’s overall well-being, and the
community context. Social workers also advocate for people suffering from chronic pain (Hauk, 2017).

Heart Disease

Two thirds of Americans will die of heart disease, and it is the leading cause of death for both women and
men. Heart disease comprises a range of conditions that affect the heart, including angina, congenital heart
disease, congestive heart failure, and blood vessel diseases such as coronary heart disease. More than half of all
deaths from heart disease occur in men. Every year about 715,000 Americans have a heart attack, and 525,000
of these are people having their first heart attack.

Exhibit 7.2 U.S. Health Care System Usage by Chronically Ill People

Source: U.S. Census Bureau (2011).

Coronary heart disease is the most common type of heart disease, killing nearly 380,000 people annually.
Alone it costs the United States $108.9 billion each year. This total includes the cost of health care services,
lost productivity, and medications (Centers for Disease Control and Prevention, 2014b). Coronary heart
disease results from coronary artery disease, where plaque buildup starts in childhood and worsens over time
unless weight is controlled and prevention measures are taken.

Heart disease is the leading cause of death for people of most ethnicities in the United States, including
African Americans, Latinos, and whites. For American Indians, Alaska Natives, Asian Americans, and Pacific
Islanders, heart disease is second only to cancer as a cause of death. Deaths vary by geography, and death rates
due to heart disease have typically been the highest in the South and the lowest in the West (Kulshreshtha,
Goyal, Dabhadkar, Veledar, & Vaccarino, 2014).

Knowing the signs and symptoms of a heart attack and taking early action are key to preventing death. Many
people are unaware of the signs, but social workers can help educate them.

Stress

Definitions of stress are highly subjective, and not all stress is bad. Basically, stress is our brain’s response to
any demand, including change. Changes can be negative or positive, real or perceived. They may be short-
term, long-term, or recurring. Change can be mild and harmless or major and traumatic. Stress is a condition
that has physiological impact. For example, stress affects a person’s thoughts, feelings, mood, and body. If

282

unchecked, stress affects sleep and leads to health problems such as heart disease, high blood pressure, obesity,
and diabetes. Leading researchers at the NIH, including Dr. Anthony Fauci and his colleagues (2008), have
described clinical manifestations of many stress-related disorders, including depression, ulcers, and
hypertension (high blood pressure).

During the past 70 years, thousands of studies and technical articles have tried to explain stress theory and the
stress response (e.g., Dohrenwend, Dohrenwend, Dodson, & Shrout, 1984; Frankenhaeuser, 1980; Lazarus,
1966; Selye, 1980). Stress responses have been studied in fields as diverse as anthropology, business,
education, law, pharmacy, philosophy, physiology, psychology, and sociology (Rice, 2012). Most of the
research has occurred in the scientific fields of medicine and nursing, because of the hypothesized relationship
between stress and illness (Aldwin, 2007).

Social workers have not contributed much to this body of research, but they have incorporated many of the
findings into their practice. For instance, social workers can assess and understand how clients get to their
breaking point. They should realize that as stress levels increase, chemicals in the brain are released that affect
the prefrontal cortex (decision-making area) and the amygdala (emotional system). People’s ability to think
logically and reasonably decreases as stress levels increase. Social workers can help clients develop stress
management skills and strategies, and can point out the four types of stress: time stress, anticipatory stress,
encounter stress, and situational stress. Through advocacy, when working with individuals, social workers help
clients fully assess situations, learn how to relax, avoid self-medication, improve emotional intelligence, and
practice time-management skills. When working with families, social workers help people keep a routine,
encourage one another, listen and communicate better, and connect and relate well. Because social workers do
not want to see people become sad, numb, or angry, or cry and cope poorly, much of their work and advocacy
is about helping people manage stress.

The health effects of stress have been widely studied in recent years.

Source: iStock Photo / PeopleImages

Time to Think 7.2

How do you define stress? Why does effective coping with stress matter?

What is your understanding of and reaction to stress? What happens to your own body when you feel stressed?

283

284

Health Disparities and the Uninsured

Health science writers continuously reveal how the dynamics of health care, poverty, race/ethnicity, age, and
gender intersect with disease. For example, not all Americans have access to the wondrous surgical procedures
available to some, such as kidney transplants, technologically advanced rehabilitation processes, and
psychopharmacology.

Socioeconomic status has been and remains persistently related to stressful and harmful living conditions,
disease, and lack of access to adequate health care. For example, when waste plants are built near
impoverished neighborhoods, health problems ensue in those neighborhoods. In addition, impoverished
people often have less access to fruits and vegetables than to candy, cookies, snacks, and cheap foods
containing large amounts of corn syrup, which leads to alarming rates of obesity and diabetes.

Unfortunately, impoverished and other oppressed people often do not have access to the health care that could
help them treat their conditions. The term health disparities (also called health care inequality) refers to gaps
between population groups in the availability and quality of health care, disease rates and severity, and overall
health (U.S. Department of Health and Human Services, 2014). In the United States, health disparities are
well documented in African Americans, Latinos, Asian Americans, Pacific Islanders, and Native Americans
(Hodge & Limb, 2010; Rhoades & Rhoades, 2014; Scheel, Prieto, & Biermann, 2011; Skinner, 2016).
Underprivileged groups distinguished by socioeconomic status or sexual orientation also experience health
disparities.

Spotlight On Advocacy

285

Heartmates
After her own husband suffered a heart attack, author and clinical social worker Rhoda Levin (1994) founded the first hospital-
affiliated program specifically designed to help the caregiver and the cardiac patient, a program called Heartmates. Her book details
how coronary artery disease can be a catastrophic chronic illness that causes problems and stress for the entire family.

Levin notes these key risk factors for heart disease: high blood pressure, high LDL cholesterol, and smoking. Other medical
conditions and lifestyle choices that put people at a higher risk for heart disease include diabetes, excessive alcohol use, physical
inactivity, poor diet, and obesity. People who are described as high-strung, Type A, or extremely stressed are often implicated as
prime targets for heart disease.

Levin tells caregivers and the public about these major warning signs and symptoms for heart attacks:

Chest pain or discomfort
Upper body pain or discomfort in the arms, back, jaw, neck, or upper stomach
Shortness of breath
Nausea, lightheadedness, or cold sweats

1. What kind of information needs to be conveyed to the family members of someone who has already had a heart
attack?

2. Where can you find local, state, and national resources to help educate others about heart disease?

One major contributor to health disparities has been a difference in access to health insurance. In the United
States, health insurance is typically provided by employers but usually only to full-time workers who are not
earning minimum wage. A 2013 report in The New York Times, using census data, revealed that about 44
million Americans have no health insurance (Bloch, Ericson, & Giratikanon, 2013). People who are medically
uninsured tend to postpone necessary care and forgo preventive care, such as childhood immunizations and
routine checkups. Uninsured people usually have no regular physician and limited access to prescription
medications. Therefore, they are more likely to be hospitalized for health problems that could have been
avoided.

More than one third of uninsured adults state that they have problems paying their bills, which explains why
many do not seek care until the last minute. When uninsured people cannot pay medical bills, the burden falls
on those who do have insurance. Billions of dollars of “uncompensated care” drive up health insurance
premiums for everyone.

286

Health Care Policy in the United States

Despite its continuing inadequacies, the U.S. health care system has traveled far. Long ago, a lone general
practitioner would make house calls, offer folk or home remedies, and take livestock as payment (Cox,
Hutton, & Hutton-Williams, 2017). Today, the United States boasts a health care complex comprising
general practitioners and specialists, clinics, hospitals, pharmaceutical companies, and health insurance
providers.

Hospitals were first conceptualized during the Civil War, and new hygienic techniques were introduced. In
1846, the first surgery using anesthesia was performed at Massachusetts General Hospital, and diagnostic X-
rays were first used in 1895. After the Great Depression in the 1930s, third-party payer (an organization other
than the patient—first party—or the health care provider—second party—involved in financing personal
health services) insurance plans, such as those provided by the federation of separate health insurance
organizations and companies referred to as the Blue Cross and Blue Shield Association, were devised to help
pay doctors and not-for-profit hospitals for their ever-more-sophisticated services. Blue Cross and Blue Shield
began as separate organizations in 1929 and 1939, respectively. In 1982, they merged to form the current
association. For-profit hospitals arrived during the 1940s. These businesses required their customers (i.e.,
patients) to pay for services and eventually crushed the public health services sector. Once employers began
providing insurance, people’s access to health care became more complicated. Insurance needed to be portable
so that when people went from one job to another, their health care would still be covered. Over time, health
insurance has become a requirement to access good health care services (Green & Rowell, 2014).

Health Insurance

Health insurance is a service you pay for but hope you will never need. Most people want and value health
insurance, but they cannot afford the coverage or have been shut out of the marketplace because they have a
preexisting condition. If a person experiences a serious illness, accident, or traumatic event, staggering
amounts of medical bills might build up and lead to bankruptcy or years of problems. Therefore, health
insurance has become necessary for all Americans.

Fast-forward to 1996. During President Bill Clinton’s administration, both Democrats and Republicans
supported the Health Insurance Portability and Accountability Act (HIPAA). The main goal of HIPAA was
to ensure that people who already had been or were being treated for a health condition could not be
discriminated against in receiving health insurance. Although HIPAA has expanded protections for people
who belong to group plans, it has not helped people who have individual coverage (Pollitz & Sorian, 2000).

In 2007, as George W. Bush was winding down his two-term presidency, he put forward a comprehensive
“Affordable Choices Initiative” to reform the private health insurance market. The goal was to harness market
forces to make private health insurance cheaper for the people who needed it most. However, because the
Democrats had just regained control of Congress, the plan was never passed. Today, Bush is best known for
his 2003 Medicare prescription-drug benefit program, often referred to as Medicare Part D.

287

Today, American citizens under age 67 are mostly insured by their or a family member’s employer. The U.S.
government provides most of the insurance for public-sector employees. Medical care is paid for through
private insurance, as well as by government programs and patients paying their own bills out of pocket. Yet
others are uninsured. Medicaid, the State Children’s Health Insurance Program, and Medicare are the federal
resources that pay for health care. The U.S. government also provides medical programs for families of
members of the armed forces and supports Veterans Affairs hospitals. A huge 65% of health care provision
and spending derives from Medicare, Medicaid, TRICARE, the Children’s Health Insurance Program, and
the Veterans Health Administration.

Time to Think 7.3

What has your experience been with the private insurance industry or with Medicare and Medicaid? What aspects of these types of
health insurance worked well? What were their drawbacks? Consider carefully whether the difficulties you encountered were due to
the insurance program itself or to your health issues or specific health care provider.

Depending on their insurance status, ill or injured people can see generalist physician practitioners or get
referrals to consult with specialists. People pay more to see “out-of-network” doctors, and some doctors are
now offering “boutique-type services,” where patients pay a yearly lump sum for present and future treatment.

Affordable Care Act

Since the debate leading to passage of HIPAA during the Clinton administration, pressure only increased to
reform the U.S. health care system more fundamentally so that more people would have insurance coverage
(Odier, 2010). The United States toyed with multiple health care reforms and solutions, but there was
contentious debate over how to balance government programs and the market-based insurance system, who
deserved to be covered, and how to pay for expanding coverage. However, data from Switzerland showed that
it was possible to provide market-based, universal, private health insurance coverage at a far lower cost than
that of health insurance in the United States, and that such an affordable health insurance system could work
(Roy, 2012). Further, a state-supported health insurance system in Massachusetts showed how reforms might
work in the American environment.

In 2010, the Patient Protection and Affordable Care Act, known simply as the Affordable Care Act (ACA)
or sometimes ObamaCare, became law. The ACA is a comprehensive health care reform law that includes
provisions to expand health insurance coverage, improve health outcomes, control health costs, and improve
the U.S. health care delivery system. The ACA also expanded public programs such as Medicaid as a “public
option” to make more disadvantaged Americans eligible for health insurance.

The ACA bill was more than 2,000 pages long. Since 2010 insurance companies have not been allowed to
deny coverage to children or adults for preexisting conditions such as asthma, HIV/AIDS, and so on. Also,
children can now stay on their parents’ policies up to age 26. Yearly limits on payouts are barred, which
protects people with catastrophic illnesses. After the initial open enrollment period, every American citizen
was required to have medical insurance by May 1, 2014, or face penalties from the Internal Revenue Service.
By 2018, all insurance plans are supposed to offer preventive care with no copayments and no deductibles.

288

The ACA was a controversial law to begin with, with opponents believing that it would lead the United
States toward socialized medicine. Some private insurance providers and health professionals opposed the law
as well, because they believed that some of the reforms would decrease their profits. And then public
enrollment in the plans in late 2013 was chaotic because of deficiencies in the computer technology
undergirding the enrollment system. Many of the ACA’s opponents were quick to predict that the act would
fail to achieve its goals.

The year 2016 marked the unfolding of a new U.S. presidential election cycle, and Brexit occurred. The year
2017 began with new Republican leadership in Washington, D.C., led by outsider President Donald Trump,
who campaigned to “repeal and replace ObamaCare.” In the first 100 days of the Trump presidency,
legislators could not come up with the votes needed to repeal the Affordable Care Act, because people were
not happy with the replacement strategy unveiled. Health care changes that emerged in 2017 may be
considered in the following top U.S. health care market trends (Santilli & Vogenberg, 2017; Stone, 2017).

The ACA. Hopefully, the requirement that companies cover people with preexisting medical conditions
will remain, and young adults will continue to be allowed to remain on their parents’ health insurance
plans until they reach age 26. The Trump administration appears to favor competition and vendor-
based incentives.
Changes in payments to physicians. In 2017 the Centers for Medicare & Medicaid Services (CMS)
released their “Quality Payment Program” changes. While it is uncertain if these efforts will result in
true savings or efficiencies in health care delivery, the measures appear to have bipartisan support in
Congress.
Rare diseases. Trump’s decision to retain ACA provisions regarding preexisting conditions and coverage
for young adults will likely drive continued interest in and growth of orphan drugs for the treatment of
rare diseases. “Purchasers and consumers will favor drugs that can cure a condition over older drugs that
merely provide palliative relief” (Santilli & Vogenberg, 2017).
Quality care. Behavioral health’s role in the delivery of quality health care will continue to grow as the
payer and provider communities promote the cost benefits of care coordination and care or case
management. Health systems appear eager to stabilize their growth around multiple mental health
services that drive revenue opportunity.
Emerging care models. Likely the United States will see a slowdown in the consolidation of hospitals and
health systems and an increased focus on value-based health care versus fee-for-service care. Health
systems may collaborate with employers, for example, in an effort to lessen the number of middleman
players and their contributions to the total cost of care.
High-value care. Determining higher-value care sites will be a focus in 2017, and will likely advance
other organizational changes by payers, purchasers, and providers in response to changing consumer
behavior. Alternate sites of care may include “in-home settings, hospital outpatient department clinics,
retail or convenience care clinics, urgent care clinics, independent or corporate freestanding clinics and
telehealth” (Santilli & Vogenberg, 2017, p. 39).
Biosimilars. Biosimilars will challenge the FDA and marketers as they become important in the
pharmaceutical company industry. A big word, biosimilar merely refers to a biologic medical product

289

that is almost an identical copy of an original product that is manufactured by a different company—yet
they are not generic drugs (U.S. Food and Drug Administration, 2015)
Cancer care. Cancer still grabs headlines. Because the United States appears to be in a thriving solutions-
based environment, clinical trials involving immuno-oncology therapy will likely continue to grow.
Payer changes. Yearly, increasing numbers of biologic and specialty drugs are being developed for rare
and chronic conditions, and this trend will likely challenge commercial insurance plan sponsors and
employers to identify what costs relate to the medical benefit versus the pharmacy benefit.
Technological innovations. Bioprinting and medical devices will emerge rapidly, as firms commercialize
technology and expertise in 3D printing capabilities that will require FDA approval.

290

Health Care Trends

Rapidly changing health care policy is accompanied by equally rapid changes in health care procedures and
protocols. Overall, the health care system now places greater focus on “benchmark practice” or continuous
quality improvement, which helps ensure that all medical personnel and administrators stay aware of
developments in health care practice and choose those that have the best outcomes for patients (Spitzer &
Davidson, 2013). Some of these systemic changes in U.S. health care are described here.

Integrative Medicine

Integrative medicine, or integrative health as it is called in the United Kingdom, is healing-oriented medicine
that considers the whole person (body, mind, and spirit), including all aspects of his or her lifestyle. It
emphasizes the therapeutic relationship and makes use of all appropriate therapies, both conventional and
alternative or complementary.

These are some of the main principles of integrative medicine (Lemley, n.d.):

A partnership between patient and practitioner in the healing process
Appropriate use of conventional and alternative methods to facilitate the body’s innate healing response
Consideration of all factors that affect health, wellness, and disease
Use of natural, effective, less-invasive interventions whenever possible
Training to make health care practitioners models of health and healing, committed to the process of
self-exploration and self-development

Social work majors can often choose to minor in holistic health, which enhances appreciation for medical
interventions beyond Western medicine, such as acupuncture and herbal remedies. The increasing need for
health social workers is especially noted in ads for bilingual and bicultural social work professionals to work as
health care navigators. Ill people seeking health care services face a maze of authorizations, CPT (current
procedure terminology) billing codes, requirements that they see a primary care provider (PCP) for referral to
a specialist, scans, tests and blood work, coordination of benefits, and pharmacy needs.

Slow Medicine

Watch any of the multiple reality television shows about medical centers, and you will observe that American
medicine seems to excel at managing crises and supplying modern technological procedures such as joint
replacements, organ transplants, eye surgeries, and cosmetic changes. For the more ordinary and common
chronic problems of aging and slow-moving diseases, our medical care system has not done as well. All too
often, patients are subjected to unnecessary, and unwelcome, stints in an intensive care unit. There is a rush to
treat people aggressively.

Slow medicine, in contrast, is the avoidance of inappropriate or harmful care and a more deliberate approach
to determining which medical procedures to follow. Family, friends, or neighbors team up with an older

291

person who has health issues and with health care providers, including home health nurses and other
providers, to improve the quality of life while the person is under medical care.

Slow medicine shares with hospice care the goal of comfort rather than cure. It is increasingly available in
nursing homes. However, slow medicine is not a plan for getting ready to die; rather, it is a plan for caring,
and for living well, in the time an older adult has left (McCullough, 2008).

Exercising is one way to promote wellness.

Source: iStock Photo / laflor

Prevention and Wellness

Giving people the resources to maintain health is just as important as helping them when they are sick, ill, or
injured. By encouraging healthy lifestyles, occurrence of preventable diseases can be reduced. Prevention and
wellness include healthy behaviors such as eating a balanced diet, exercising regularly, scheduling regular
physical examinations, and following a doctor’s recommendations.

Recovery, Rehabilitation, and Resilience

When people become ill, injured, or disabled, time is often required to rehabilitate and recover. During the
recovery and rehabilitation process, social workers educate people about how to reduce risk factors and
increase protective factors.

Health care professionals may also assess resilience levels. Resilience is an interaction between risk and
protective factors within a person’s background that can interrupt and reverse a potentially damaging process.
It is a trait, and a major strength, that allows a person to “bounce back” from difficulties. In the health care
context, it may facilitate recovery from disease, injury, and medical procedures.

Time to Think 7.4

How do you define resilience? How resilient do you think you are? How resilient do you perceive your parents to be? How has their
resilience affected yours—or vice versa?

Inflammation

Inflammation—the body’s attempt to protect itself from damaged cells, irritants, or pathogens so that a
healing process can occur—is receiving an incredible amount of attention in medical journals these days.

292

Inflammation, from the Latin inflammo (meaning “I set alight, I ignite”) is part of our body’s immune
response and is initially beneficial; for example, when you hurt your knee, it swells and the tissues require time
to heal. However, inflammation can be self-perpetuating and cause more inflammation.

There are two types of inflammation:

Acute inflammation is the inflammation that occurs in the immediate or short-term aftermath of an
injury or disease. The five hallmarks of acute inflammation can be remembered by the acronym PRISH,
which refers to the signs of inflammation: pain, redness, immobility, swelling, and heat. Pain is when
people have inflammation and it hurts; they feel stiff, uncomfortable, or distressed and in agony
depending on its severity. Pain can be constant or steady, such as an ache, or it can be a throbbing type
with pulsating pain or a stabbing, pinching pain. Pain is an individual experience, and the only person
who can describe it properly is the one who is feeling it. Pain can be acute or chronic
(www.medicalnewstoday.com).
Chronic inflammation lasts for several months or years and can occur as a result of an autoimmune
response, a chronic irritant, or failure to eliminate the cause of inflammation. Examples of diseases and
conditions that produce chronic inflammation are asthma, chronic peptic ulcer, tuberculosis, rheumatoid
arthritis, chronic periodontitis (infected gums), ulcerative colitis and Crohn’s disease, chronic sinusitis,
and chronic hepatitis, to name a few. The risk of chronic inflammation is much greater if the person is
obese.

Inflammation may be treated with anti-inflammatory medications (naproxen, ibuprofen, aspirin), herbs
(hyssop, ginger, turmeric), and other treatments (applying ice, taking fish oil or omega-3 fatty acid
supplements, drinking green tea, eating tart cherries).

Managed Care

Managed care is a type of health care system created to manage, or contain, health care costs. Managed care is
offered primarily through the private sector, although Medicaid and Medicare are also forms of managed care.

Managed-care plans include the following variations:

Health maintenance organization (HMO).An HMO is a coordinated delivery system that combines both
the financing and delivery of health care for enrollees. In each plan a member is assigned a “gatekeeper”
primary care physician who is responsible for the overall care of that member. In an HMO plan,
patients pay less in insurance premiums and a nominal copayment (“copay”) at the time of service. The
idea of a “health maintenance strategy” was first proposed by Dr. Paul Elwood in the 1960s, and the
concept was promoted by the Nixon administration as a fix to rising health care costs. HMOs are
licensed at the state level.
Preferred provider organization (PPO).A PPO generally does not require copays and instead requires
that patients cover a “deductible” (a preset sum for any service) before any benefits are provided. After
the deductible is met, the insurance company and the patient split the costs of benefits.

293

A point-of-services plan combines features of PPOs and HMOs. What they all have in common is that
patients must be preauthorized by an insurance carrier to qualify for specific services; patients with managed-
care plans cannot simply make an appointment with any doctor. Exhibit 7.3 provides a breakdown of
distinctions among managed-care organizations.

The growth of managed care in the United States was triggered by the enactment of the Health Maintenance
Organization Act of 1973. Today managed care is almost ubiquitous in the United States but has been
controversial because of its mixed results in trying to control medical costs. Proponents of managed care
believe that it has increased efficiency, improved overall standards, and led to a better understanding of the
relationship between costs and quality. It has promoted the practice of evidence-based medicine, which is now
used to determine when lower-cost treatment may be more effective. Critics of managed care argue that “for-
profit” managed care has been an unsuccessful health policy because it has contributed to higher health care
costs, increased the number of uninsured citizens, driven away health care providers, and applied downward
pressure on quality.

Current Trends

294

Medical Advice About Obesity
Obesity has been linked to many diseases and types of illnesses, including inflammation, heart disease, diabetes, high cholesterol,
and high blood pressure. In the past, doctors have not emphasized the risks of obesity to their patients. They would say, “You have a
problem with your weight” (Perkes, 2013). The patient would agree and then go home and fall right back into old patterns. The
weight would never come off, and the risks would remain.

Over the past couple of years, however, doctors have begun to try motivational interviewing as a way to get patients to change
(Perkes, 2013). The technique centers on the patient and doctor deciding together what the patient wants to accomplish and how to
go about doing it. Health social workers require skills in motivational interviewing and interventions.

1. How can social workers respond on the micro, mezzo, and macro levels to lessen obesity?
2. How effective might motivational interviewing be in helping people change their eating habits?

Electronic Medical Records

National policy changes have prompted the adoption of electronic medical records (EMRs), which allow
physicians to maintain electronic files of lab results, visit notes, diagnostic test results, insurance information,
demographics, health histories, and other medication information within their offices. The companion to
EMRs are EHRs (electronic health records), which facilitate the electronic exchange of EMRs between
providers, thereby allowing the medical record to “follow” patients when they see different providers (Spitzer
& Davidson, 2013, p. 966).

EMR and EHR use is promoted by the ACA as essential to efficient health care delivery systems. Health care
organizations are increasingly migrating toward a paperless environment. Exhibit 7.4 lists some pros and cons
of electronic storage and transmission of individuals’ medical records.

295

Health Care and Social Work

Health social workers have long provided people with biopsychosocial-spiritual support needed to cope with
acute illness, chronic illness, or terminal illness. Services provided by professional health social workers
include advocating for patients and family caregivers; assessing needs; providing care and case management;
educating and counseling; intervening to promote health, prevent disease, and address disparities and barriers
to health care; and providing information and referrals. Because health care is “big business,” social workers
can also take business and accounting classes to help prepare them to manage community-based agencies and
social service organizations.

Health care social workers require interdisciplinary knowledge about acute and chronic illnesses, accidents and
injuries, genetics and birth abnormalities, neuroscience, and death. Hospice workers in particular require a
comfort level with end-of-life and palliative-care issues. Medical social workers, often at the MSW level and
in specialized ways, are in demand in many parts of the nation for employment in hospitals, the Veterans
Administration, and various types of health care facilities.

296

History of Health Social Work

In 1905, at Boston’s Massachusetts General Hospital, physician Dr. Richard Cabot hired a competent and
dynamic medical social worker named Ida Cannon, who created the first hospital social work department. At
this time, antibiotics, advanced X-ray technology, the human genome project, and managed-care
organizations were nonexistent.

Health social work was one of the first three fields of practice established in the social work profession. Early
medical or “health social workers” were the first social work specialty group to organize formally as
professionals, and they shared a mutual concern for how poverty was affecting individual health outcomes and
public health. Health social workers offered ill, injured, or suffering people and their loved ones social support
and advocacy.

They endeavored to humanize people’s hospital experiences and coordinate community resources. In 1918,
the American Association of Hospital (Medical) Social Workers was founded and began publishing its own
journal. In 1929, 10 college-level medical social work courses were created and offered. At this time,
psychoanalytic thinking (or Freudian thought) was in vogue, and health social workers focused on diagnoses
and mental health challenges. Community-based social workers focused on public health and social concerns
such as tuberculosis, sexually transmitted infections, and sanitation.

Exhibit 7.3 Managed-Care Organization Distinctions

Source: Odier (2010).

Exhibit 7.4 Advantages and Disadvantages of Electronic Medical Records

Source: American Medical Association (2014).

When the Social Security Act of 1935 was passed and implemented, the social work presence in health
settings grew. Social worker Grace Abbott helped write this legislation. Subsequently, the American Public
Health Association and the American Hospital Association created standards for health social workers.

297

Indirect social work practice in health settings began at the start of the 20th century, and sociologist Homer
Folks, along with many others, worked hard to manage epidemics and debilitating diseases by focusing on
prevention efforts and community systems change. In the hospital and in the community, Cannon, Abbott,
and Folks advocated for good sanitation, adequate housing, and health improvements for individuals, families,
and communities.

298

Social Workers’ Roles in Health Care Practice

The goals for health social workers are outlined in the revised NASW Standards for Social Work Practice in
Health Care Settings (National Association of Social Workers, in press b):

Ensure that the highest quality of social work and client- and family-centered services are provided to
clients and families in health care settings
Advocate for clients’ rights to self-determination, confidentiality, access to supportive services and
resources, and appropriate inclusion in medical decision making that affects their well-being
Encourage social work participation in the development, refinement, and integration of best practices in
health care and health care social work
Promote social work participation in systemwide quality improvement and research efforts within health
care organizations
Provide a basis for the development of continuing education materials and programs related to social
work in health care settings
Encourage social workers in health care settings to participate in the development and refinement of
public policy at the local, state, and federal levels to support the well-being of clients, families, and
communities served by the rapidly evolving U.S. health care system
Inform policymakers, employers, and the public about the essential role of social workers across the
health care continuum

Health care social workers provide services across the life span, from neonatal intensive care units to skilled-
level long-term care settings. Their purpose is to help people and families cope with illness or injury, prevent
emotional and social issues from negatively influencing health, and address service delivery shortcomings.
They may be scheduled 24/7 or be on call in case an emergency or crisis arises.

As you might imagine, crisis intervention and grief counseling are common health social work roles, as are
chart documentation and debriefing with colleagues. Some of the other roles are discharge planning; chemical
dependency evaluation; mental health assessment; short-term decision-making counseling; ethical decision-
making counseling; facilitating support groups (e.g., cancer support groups, rehab family groups); specialty
evaluations and coordination, such as on a renal transplant team; and child abuse investigations and reporting.

Noted earlier, hospitals are a growing source of jobs for social workers, and those who work in hospitals expect
to juggle hefty caseloads and remain on call. A typical day in a hospital may start with a review of new
admissions, current referrals, walking rounds or sit-down multidisciplinary health care team meetings, family
meetings, patient assessment, and discharge planning. Large teaching hospitals are found in cities and
metropolitan areas; community hospitals are most often found in rural geographic areas. Social workers in
teaching hospitals must have an MSW degree.

Regardless of workplace environment or client population, health social workers must be clinically and
culturally competent. They must also be aware of factors driving health care practice, including the priorities,

299

missions, capabilities, and limitations of the hospitals, clinics, and other organizations (Spitzer & Nash,
1996). Environmental and organizational awareness are essential to 21st century social workers who work in
health and disability settings and fields of practice.

300

Health Care Settings

Multiple types of health care organizations employ social workers. For example, health (medical) social
workers work in acute care, hospitals, home health, long-term care, hospice and palliative care, clinics, and
rehabilitation. All these health care settings are practice areas in which assessment, care, and treatment
address the physical, mental, emotional, and social well-being of the person. Health settings address
prevention, detection, and treatment of physical and mental disorders with the goal of enhancing the person’s
biopsychosocial and spiritual well-being.

Social Work in Action

301

Karyn Walsh Practices Health Care Social Work Across Multiple
Settings
Karyn Walsh (LCSW, MSW) tells her own story: As an undergraduate, my degree was in social work. I felt a calling, of sorts, to
help people. My first practicum experience was volunteering at a homeless shelter, where I learned much about community resources
—food banks, congregate meals, and more.

As I pursued my MSW, I chose the health track over those in mental health, juvenile justice, and administration. In my first field
experience, I felt fearful and uneasy helping hospice patients die with dignity. Eventually, I grew comfortable with end-of-life and
palliative-care issues.

With my MSW degree, I landed a job at a community nonprofit hospital and was primarily assigned to orthopedics but also cross-
covered neurology and oncology. I adored the fast pace of hospital-based health social work and became a whiz at efficient discharge
planning. Sometimes after-hours oncology nurse Perry and I cofacilitated an “I Can Cope” support group for family members of
patients who were living with and dying from multiple types of cancer. I participated in 7 a.m. walking rounds every Monday and
Friday, and multidisciplinary team meetings.

After getting married and moving, I held a hospital social work position that served a wide range of populations and demographics,
including military families. This position allowed me to accrue enough supervision hours to take the LCSW (licensed clinical social
worker) exam, and I passed on my first try. My license allowed me to place my name on rosters with select insurance companies, and
I began to provide per diem counseling to clients on the outside.

Following my family’s second move, I became the program director for a grant-funded program that served people with hemophilia.
In this capacity, I found myself working with clients who had hemophilia and HIV/AIDS. This job gave me an insider’s view to the
world of public health politics, stigma, and discrimination, as I watched several men with hemophilia die from the ravages of
advanced AIDS.

Four years later when we moved to the suburbs of Washington, D.C., I accepted a job at the National Association of Social Workers
headquarters. Great flexibility was afforded to me in this position. I worked some at home and took the metro or drove into the city
a couple of times a week. Creativity, educational and technology skills, and macro social work skills were required for this position. I
enjoyed designing curricula, organizing national webinars, revising policy brochures and practice standards, and interacting in a
liaison capacity with other professional organizations. This position required that I keep up with the latest funding pots and policy
changes being made by the Substance Abuse and Mental Health Services Administration, Center for Medicaid Services, Centers for
Disease Control and Prevention, and more.

I next worked outside Washington, D.C., as a home health social worker. My child was in school, and I wanted the flexibility to
accept work when I could and decline cases when I needed to attend to my child and her activities. The massive amounts of
knowledge I acquired over the years in hospitals, outpatient clinics, clinical trials, and per diem hospice and mental health counseling
work served me well. After a couple of initial orientations with other home health social workers and various therapists and nurses, I
happily transitioned to the job I have today in home health social work.

Each day is an adventure. Some days I drive down dirt paths to small homes in impoverished areas. Then the next day I might park
in a well-monitored parking lot and take the elevator up to a penthouse suite overlooking Washington, D.C. I help people who have
illnesses, injuries, or disabilities and are in need of health care services, community resources, and/or counseling. As a frontline
practitioner involved in direct social work, I increasingly see the immense influence of state and federal policies on my patients’
ability to access services and get services paid for.

1. What benefits has Karyn derived from obtaining a social work degree?
2. How might Karyn’s cumulative work experience benefit her clients?

The health care setting includes personnel who provide the necessary services (e.g., physicians, nurses, social
workers, hospitalists, care managers), appropriate service delivery facilities (e.g., hospitals, hospices, assisted-

302

living facilities, nursing homes, medical centers, urgent care centers, and outpatient clinics), and educational
and environmental facilities that work to help prevent disease.

In the United States, health care is provided by multiple distinct organizations mostly owned and operated by
private businesses. For example, about 62% of U.S. hospitals are nonprofit, 20% are government owned, and
18% are for-profit.

Emergency Rooms and Trauma and Urgent Care Centers

Emergency rooms (ERs) are equipped and staffed to deal with traumatic injuries and acute diseases. ER social
workers require special training to work with patients experiencing chemical dependency and abuse concerns
(Cesta, 2012; Fusenig, 2012). Urgent care centers or facilities are convenient walk-in options for people with
non-life-threatening health situations, when their own doctor is unavailable. Some urgent care centers charge
less than half the cost of an ER or hospital visit. Others offer self-pay discounts for the uninsured. Some of
these centers use printable coupons that can be applied to the cost of self-pay pricing for urgent care on the
patient’s next visit.

Oftentimes medical residents moonlight at urgent care centers (also referred to as a “doc-in-the-box”—
implying that any kind of doctor might be there when you walk in) for extra money and practice experience.
But uninsured people often are unable to use community urgent care centers, unless they can financially
manage the posted pricing fees; so they visit ERs instead. This has drastic effects on hospital budgets. ERs are
expensive to operate, waits can be extremely long, and staff turnover is high.

Many of the ERs at public hospitals are especially impacted by heavy use by the uninsured and constant
demands for budget cuts. As resource cuts continue, ER social workers may need to advocate on a macro level
for continuation of services for poor and indigent patients. Social work’s cost-effectiveness in hospital ER
settings has been well documented (Auerbach & Mason, 2010). Emergency department (ED) social workers
play a vital role in helping avoid unnecessary admissions and improving patients’ quality of life. ED social
workers possess good crisis intervention skills and can perform accurate and quick assessments. They quickly
build rapport, help triage accident victims, manage people who have mental disorders, and counsel victims of
violence and others. These same ED social workers can be tremendously supportive of other staff in the ER.

Hospitals and Acute Care

Inpatient hospital care settings employ—in addition to social workers—nurses; occupational, physical, and
speech therapists; dieticians; X-ray and operating room technicians; hospitalists; and more. Insurance
reimbursement for inpatient hospitalizations varies depending on a person’s age, diagnosis, and insurance
coverage or work status.

Hospitals may be small or large, community-oriented nonprofit, private for-profit, or specialized to serve
populations such as veterans and people with mental illness. Public, private, and Veterans Affairs hospitals all
strive to equip themselves with specialized treatment equipment, laboratory facilities, and skilled technicians.

303

Hybrid hospital services also exist. Some ambulatory care entities integrate rehabilitative and mental health
services for people capable of getting out of the hospital bed and beginning recovery. For extensive skilled or
rehabilitative care, hospitals sometimes house transitional care units (or they may send patients to community
long-term care settings).

Some health social workers are called to advocate for aging immigrants and refugees, who often present with
anxiety, depression, and other mental health problems that may create physical health problems. It is not
uncommon for immigrants and refugees to have been persecuted, to have lost loved ones, and also to be
uninsured. When immigrants and refugees do not know where to go for illnesses or injuries, they may land in
an ER or hospital bed feeling overwhelmed and alone. As the ACA hopes to provide health care coverage for
the uninsured, social workers may likely be the people who help immigrants and refugees make sense of a
“foreign system.” Findings from some social work researchers reveal how the role of hospital-based social
workers is changing as a result of the ACA and immigration and deportation practices (Judd & Sheffield,
2010; Reisch, 2012; Sullivan & Zayas, 2013).

Direct patient care activities, such as discharge planning, consume the majority of hospital social workers’
time. Direct practice includes counseling and crisis intervention, yet rarely includes bioethics, evidence-based
practice, or income-producing projects (Judd & Sheffield, 2010).

Veterans Affairs Hospitals

Veterans Affairs (VA) hospitals and military social work emerged after World War II. Presently, VA hospitals
are among the largest employers of MSW social workers, as multiple members of the armed forces are
returning home with trauma, physical injuries, and disabilities.

Critics have lambasted VA health care for excessively long wait times and bad practices (Olson, 2014).
However, VA hospitals are leveraging technology to reduce the distance veterans have to travel, increase the
flexibility of the system they use, and improve their overall quality of life. For example, in 2012, the
Department of Veterans Affairs announced it would no longer charge a copayment when veterans receive care
in their homes via video conferencing with VA health professionals. This clinic-based telehealth program
involves more than 800 community-based VA outpatient clinics where many veterans receive primary care,
and the program improves access to general and specialty services in geographically remote areas where it can
be challenging to recruit mental health professionals. That same year, the VA added more than 1,600 mental
health clinicians and more than 300 support staff to help address the increased demand for mental health
services among veterans. The additional staff included nurses, psychiatrists, psychologists, and social workers.
Pressing concerns for VA social workers revolve around compassion satisfaction, compassion fatigue, and
burnout (Beder, Postiglione, & Strolin-Goltzman, 2012).

Home Health Care

Home health is both public and private. Agencies such as the Instructive Visiting Nurse Association, Anova
Health Care System, and Jewish Family Service depend on the skills of nurses, occupational and physical

304

therapists, and social workers to assess people and provide in-home health care services.

Because institutional structures are costly to maintain, the demand of home health care is expected to increase
exponentially as the baby boomers continue to age and the population of people with chronic illnesses and
disabilities continues to grow.

Long-Term Care

The term long-term care, often synonymous with nursing home care, implies that some people require
supportive health care for a long time—maybe for the rest of their lives. Family or friends often cannot
provide such intensive care themselves; the job is strenuous, laborious, and time-consuming (Meyer, 2000). By
federal law (42 CFR 483.15) nursing homes with more than 120 beds are required to employ a full-time social
worker with at least a bachelor’s degree in social work or “similar professional qualifications.” Facilities with
fewer than 120 beds must still offer social services; however, they are not required to have a full-time social
worker on staff. Preferably, a nursing home will hire a social worker from an accredited school of social work
who is licensed, certified, or registered within his or her home state. Long-term care social workers make
home visits, perform intake assessments, handle discharge planning, facilitate resident and family council
meetings, provide educational training, and much more.

Hospice, End-of-Life, and Palliative Care

As the end of life approaches, health care can take a far different approach. Instead of aggressively treating a
disease or injury—with surgeries, medications, and life-support devices such as breathing apparatus and
feeding tubes—the patient is allowed to die peacefully and with dignity. Family and friends also get the
support they need. Hospice and palliative care focus on caring, not curing.

Hospice care becomes available when a patient faces a terminal illness or painful injury and is believed to have
6 months or less to live. Hospice is not a place, per se; care often occurs in a person’s home. Occasionally,
hospice social workers visit residents in nursing homes and hospitals to conduct intakes. Hospice involves a
team-oriented approach to expert health care, pain management, and emotional and spiritual support that is
tailored to what individuals need and want. Support is also provided by and for a patient’s loved ones. Hospice
is considered the model for quality, compassionate care.

Palliative care focuses on relieving and preventing the suffering of patients, whether they are expected to die
soon or not. It is provided by physicians, nurses, and social workers who specialize in the relief of pain,
symptoms, and stress that accompany serious illness. However, like hospice, palliative care embraces the idea
that at the end of life, comfort is more important than continued aggressive treatment. Social workers help
people face terminal illness, find peace, and appreciate life (Faherty, 2008).

Rehabilitation Services

Rehabilitation in health care refers to bringing a person back to a normal, healthy condition after an illness,
injury, drug problem, or the like. It can take many forms: vocational rehabilitation, rehabilitation after

305

neurological or traumatic brain injury, addiction or substance use recovery, or physical and occupational
therapy rehabilitation. It can take place in hospital-based transitional care units, or in community-based long-
term care settings or other outpatient settings. Patients who reside in rural and suburban areas may have
limited access to public transportation and depend on family to help them get the type and level of
rehabilitation services they require.

Clinics

When doctors share offices, administrative personnel, and medical equipment for everyday health care needs,
they are operating a clinic. Some clinics are privately owned by the doctors or by health care companies
operating strings of clinics under a particular brand name. Public health clinics and ambulatory care clinics
may be connected to large and small hospitals, and they often employ social workers to conduct assessments,
link people with community resources and entitlement programs, and educate people about health diagnoses
and prognoses.

Freestanding clinics for the homeless, indigent, or working poor also meet an important need for hundreds of
uninsured Americans, especially in urban areas. Physicians may work pro bono to run these clinics. Social
workers are also present to offer behavioral and cognitive interventions and care-management services to
homeless veterans, the severely mentally ill, people with substance use problems as well as mental illness, and
the uninsured working poor.

Current Trends

306

Social Workers as Health Care Navigators
Primary care used to be considered a client’s first entry into the health system. Clients would call to make an appointment with a
medical professional and put their health issues in that professional’s hands. Increasingly, however, primary care in the United States
and Canada is multidisciplinary and transdisciplinary, with nurses, social workers, and other community providers working in
tandem and in teams with physicians, especially when the patient has a chronic illness. Health care has become, as a result, a
complex process.

Vital Decisions is a U.S. company that represents a new trend in guiding those who are ill through the health care system (Gordon,
2014; Vital Decisions, 2014). It hires expert staff (who may be social workers) as navigators to help people make health care
decisions. Via a series of phone calls, navigators review a person’s medical situation and help develop a plan to address health care
decisions that person is currently facing or may face in the future.

Social workers employed by Vital Decisions may also call terminally ill patients. The intent is to avoid futile medical care and thereby
reduce health care costs by engaging in increased communication about palliative care.

1. With what ethical issues might a Vital Decisions social worker have to grapple?
2. What skills would be required to be a social worker for Vital Decisions?

Public Health Services

A public health social worker focuses on the general well-being of small (villages or boroughs), medium (cities
or towns), or large communities (nation) and their residents. Public health social workers may help implement
communitywide programs or help alleviate individuals’ suffering. Workers may make home visits and conduct
community health fairs, or assist with seminars about vaccinations. Local, regional, state, national, and
international entities may become involved in providing health services for a population. Public health care
providers focus on prevention of disease, especially contagious diseases. Public health departments, which are
usually local or state agencies, provide a broader array of services:

Testing, counseling, and vaccinations
Prenatal and postpartum care, nutrition, and medical care
Physical rehabilitation to people who experience strokes and other debilitating health events
School medical care to parochial and public institutions
Codes, rules, and regulations to ensure that the air, water, and food are protected and that waste is
properly disposed of (environmental sanitation)

In addition, state health departments or divisions maintain records of area births, deaths, marriages, and
current communicable diseases. At the state, national, and international level, public health agencies distribute
health education and information to teach the general public about health and prevention of illness.

307

Diversity and Health Care

Health disparities that are experienced by disadvantaged populations result from multiple factors, including
poverty, environmental threats, inadequate access to health care, individual and behavioral factors, and
educational inequalities. Fortunately, health disparities are preventable differences in the burden of disease,
injury, or violence, and in opportunities to achieve optimal health. However, it is important to recognize that
health disparities are directly related to the unequal distribution of social, political, economic, and
environmental resources (Centers for Disease Control and Prevention, 2013). Social workers have been
staunch advocates for minimizing health disparities and lessening stigma toward people with health problems.
In health care, the legacy of health social work is challenging, complex, and exciting.

Age. Aging results in greater health care demands and increased costs. In America large numbers of
people are aging and putting great pressure on the health care system. People over 80 are the fastest-
growing segment of the population. When people age beyond 65, they become eligible for Medicare.
Both Medicare and Medicaid long-term care expenditures are doubling, thereby causing increased
taxpayer-funded costs for younger working people. At the same time, efforts to put Medicare and
Medicaid on a sounder footing have been victims of political debates about government budgets. The
result is some so-far-mild resentment of retired workers who are assured of receiving health care in old
age, whereas younger workers do not feel so secure.
Race and ethnicity. In the United States, whites have a much longer life expectancy than most racial and
ethnic minority groups. By the year 2030, 1 in 4 Americans over age 65 will be from a racial or ethnic
minority. Racial and ethnic minorities tend to receive lower-quality care than do nonminorities;
therefore, patients of minority ethnicity experience greater morbidity and mortality from various chronic
diseases than do nonminorities. For older adults of color, often their health issues are affected by their
class, subculture, and sexual orientation. Consider how African American women over age 50 are
contracting HIV disease at alarming rates, with little attention given to their prevention needs. Also
think about why diabetes is the fifth-leading cause of death in the Asian American and Pacific Islander
population.
Class. The upper class has a distinct advantage over the less affluent with regard to life expectancy.
People with low incomes live approximately 7 years less than the more affluent. The more affluent use
more preventive health services and are less likely to delay seeking care when sick (Weiss & Lonnquist,
2016). Health disparities are also related to class and inequities in education. Dropping out of school is
associated with multiple social and health problems, and less-educated people are more likely to
experience health risks, such as obesity, substance use, and intentional and unintentional injury. Higher
levels of education are associated with a longer life and an increased likelihood of obtaining or
understanding basic health information and services needed to make appropriate health decisions
(Centers for Disease Control and Prevention, 2013).

Free clinics allow individuals to access health care at little or no personal cost.

308

Source: iStock Photo / Steve Debenport
Gender. Females have a longer life expectancy than males. Mortality rates for the leading causes of death
(e.g. heart disease, cancer, and stroke), are higher for men than women. Ironically, women report more
sickness than men, yet live an average of 7 years longer. While women are less likely to have a chronic
health condition, they appear to be more at risk for acute illness and disability compared with men.
There is concern that reductions in Americans’ fertility, greater women’s labor force participation, and
increases in the divorce rate may reduce the ability of families to take care of older women who are ill,
placing even greater demands on social and public programs.
Sexual orientation. Sexual minorities are at increased risk for certain negative health outcomes. For
example, young gay or bisexual men have disproportionately high rates of HIV, syphilis, and other
sexually transmitted diseases. Adolescent lesbian and bisexual females are more likely to have been
pregnant than their heterosexual peers (Centers for Disease Control and Prevention, 2012a). Gay men
and women are also more likely to smoke cigarettes. Lesbian women and bisexuals are more likely to
report having multiple risk factors for heart disease (Northeastern University Institute on Urban Health
Research, 2010). Sexual minorities as a whole are more likely than their heterosexual counterparts to
report experiencing some form of sexual assault during their lifetime. Health care social workers will
need to understand terms specific to gender expression, such as cross-dresser, drag king or queen, passing,
and transition. Also, terms specific to sexual identity and sexual orientation require understanding, such
as bisexual, gay, lesbian, coming out, questioning, and MSM/WSW (men who have sex with men/women
who have sex with women).
Intersections of diversity. Multiple dimensions of diversity complicate and compound people’s health care
needs. We see how health care disparities translate into real health outcomes when we read how African
American women with breast cancer are 67% more likely to die from cancer than are white women
(Joslyn & West, 2000).

309

Advocacy on Behalf of People With Health Care Challenges

When visiting or counseling patients or their families and friends in hospital rooms or hospice, social workers
often witness physical and emotional pain. Those are the times that often galvanize social workers to become
better advocates for people experiencing health care challenges. No matter the setting or client concern,
human needs must be met so healing and acceptance can occur.

310

Economic and Social Justice

The complexity of the U.S. health care arena means that social work advocacy efforts are required in multiple
places, spaces, and areas of health care. Health social workers, in particular, help people obtain insurance and
translate or interpret complex and confusing insurance policy language. Older adults might need to better
understand the intricacies of Medicare Part D, whereas parents of a young child with autism or epilepsy may
benefit from understanding how such health concerns will change across the life course.

Insurance. In the United States, accessing good health care services depends on one’s insurance coverage.
Marketplace values that are noted in policy language—for example, “levels of care,” “market exchanges,”
and “medical homes”—are often incomprehensible to people seeking insurance. Government programs
such as HIPAA, Children’s Health Insurance Program, Medicare Part D, and the ACA also have
complex rules and regulations. Social workers must often interpret the language of health insurance for
clients.
Chronic disease. The personal and economic burden of chronic disease and illness is a serious challenge
for Americans and U.S. health care policy. Too often, health systems do not recognize chronic illness
because it does not fit into biomedical or administrative classifications, and health care has become a
business where bureaucratic systems reign supreme.
Hospitals. Accessing hospital care is not simple. First you get a diagnosis, and then the expected medical
activity of identifying and treating an unhealthy condition occurs. Additionally, much coordination of
services and insurance tracking systems is required. Private for-profit organizations render health care
services differently than do public government-supported entities. Administrative costs for insurance
vary; hence, the implication is that the cost for premiums will vary and may be higher for those seeking
care from private for-profit organizations rather than single-payer entities that accept Medicare or
Medicaid insurance.
Outpatient services. Some patients require services outside of a hospital. And now community-based
physician group practices are charging fees for using their services, just like those patients would pay if
they were being treated in a hospital.
Veterans health care system. By law, the Department of Veterans Affairs is required to provide eligible
veterans with hospital care and outpatient care services (treatment, procedures, supplies) that are defined
as “needed” or that will restore health. Veterans may be eligible for health programs related to
HIV/AIDS, Agent Orange exposure, or blindness rehabilitation. VA social workers may work with the
Homeless Veterans Reintegration Program; counsel armed forces members living with posttraumatic
stress disorder, a traumatic brain injury, or a substance use problem; or work with the Disabled
American Veterans organization. Because of scandal and bad press related to health care at VA
hospitals, veterans are now eligible for a portable and comprehensive health care package. However, to
receive this health care, armed forces members and veterans must be enrolled. Military social workers
can help educate people about the existence of such resources.
Race and class impact. Both race and class affect mortality. While some life expectancy and mortality
differentials may have a genetic basis (e.g. diabetes, sickle cell anemia, and hypertension in African

311

Americans), social-environmental factors play a more significant role, and the majority of these factors
are related to higher rates of poverty among minorities. Poverty reduces life expectancy by increasing the
chances of infant mortality, acute and chronic diseases, and traumatic death (Weiss & Lonnquist, 2016).

312

Supportive Environment

There is no doubt that where you live, whether in a rural or suburban area or a city, dictates the type and
variety of health care available to you. Accessing health care can be a problem when you reside in a remote
area. You might not be able to get to a hospital quickly in an emergency. You also might not want to travel
long distances to get routine checkups and screenings, and thus you may resort to telehealth services. Rural
areas often have fewer doctors, dentists, and social workers, and certain specialists might not be available.
People in rural areas of the United States have higher rates of chronic disease than do people in urban areas.
They also have higher rates of certain types of cancer, from exposure to chemicals used in farming. Because it
can be difficult to access care—especially for the poor and some people of color—health problems in rural
residents may be more serious by the time they are diagnosed (Nelson & Gingerich, 2010).

The hallmarks of urban settings—size, diversity, density, and complexity—give rise to unique health problems
having to do with sanitation and communicable diseases. However, suburban and urban residents also have
greater access to advanced technology, screening services, and clinical trials, and they have greater proximity to
dialysis facilities, VA hospitals, and long-term care or residential group homes. It is important to note,
however, that taking advantage of these health care resources may require some sophistication, money or
insurance, and transportation, and thus often requires social work advocacy.

Time to Think 7.5

Do you think that space and place could have an effect on our immune system and stress response? Think about how different places
affect your health. Does it seem as though you become more tired or stressed than usual or tend to get sick in any particular place?
Are there environments that seem more supportive to your health?

313

Human Needs and Rights

The adage, “If you have your health you have everything,” speaks to the utmost value Americans place on
good health. Living a disease- and illness-free life seems like a basic human need. However, too many youth,
young adults, and poor people remain uninsured, and not everyone who has health insurance receives
equivalent services. When serious illness strikes, only some people are able to access lifesaving treatments—for
instance, not everyone is eligible for an organ transplant.

People at any level of society value health care characterized by personal choice, ethical decision making,
resources to maximize health or well-being, and the chance to be understood and respected. When such values
or needs are compromised because of health disparities or stigma and discrimination, we all suffer. Social
workers get involved in health advocacy by helping someone with a substance use problem get into treatment,
working in the foster care system, or helping families and children with mental illness. As consumer-driven
health care plans and other cost-saving measures are shifting more responsibility to the employee, social
workers render health advocacy via employee assistance programs to help people with complex health and life
issues. Some health advocacy services are simply a call center staffed by health advocates and supported by
social workers.

314

Political Access

Health care–related policies are political. Perhaps the most glaring and recent example is the heated debate
over the ACA, which continued for years after it was passed into law and began being implemented.
Although it was popular among U.S. citizens, legislatures and courts continued to attack it.

Medicines have been a different matter. Because of a 1984 law, prompted in part by public outcry, America is
blessed with the most efficient market for generic drug substitution in the developed world. About 80% of
drugs prescribed in America are generics, compared with 12% in France and 7% in Italy—two countries with
socialized systems and drug price controls (Organisation for Economic Cooperation and Development, 2013).
Prices came down as well, because drug manufacturers were encouraged to compete with one another after a
drug’s patent expired.

Political factors affecting current health social work practice include both stressors and opportunities.
Tremendous demographic, economic, social, political, and operational system issues are causing dynamic
changes in the delivery of health care, and social workers need to respond with creativity and tolerance for
ambiguity (Spitzer & Davidson, 2013). Consider the large aging population, the increased use of health care
technologies, new integrated provider systems, models, anticipated changes in practice techniques, and
skyrocketing costs and fees. Gerontology social workers can help create additional community health services
that help older adults age in place, and help these same elders understand how to use assistive devices and
technology. Public health social workers can focus more on prevention and education and work collaboratively
with other health care providers.

At the micro level, social workers can help clients access health services and obtain better health literacy—
especially for people who speak languages other than English and/or do not understand complicated medical
jargon, or who do not have the capacity to comprehend policy language.

Another avenue for political advocacy is to learn more about the ways other societies address their health care
issues, and then share that information with clients, colleagues, and decision makers. Travel internationally
and you will see how health care services in other countries are delivered quite differently than in the United
States. Go to Norway and ask citizens why they are required to pay more taxes that go directly to health
services. Visit a hospital in Heredia, Costa Rica, and note how the corridors connecting hospital rooms are
outdoors and greenery abounds. Both solutions create health benefits for the populations of those countries.
For example, survey research has shown that when hospitalized patients saw water and trees, they were less
anxious and required less pain medicine than those who looked at abstract art or no pictures at all (Franklin,
2012). Exhibit 7.5 lists the existing programs and reforms for health care in the United States.

315

Your Career in Health Care

No matter the health care context, the health social work job market is exploding with opportunities as the
ACA legislation rolls out, multiple veterans return injured from combat, and digital technology radically
changes the fields of dentistry, surgery, and general medicine to help people live healthier and longer.
Historically, and still today, health social workers have provided concrete resources, counseling services, and
patient advocacy (Judd & Sheffield, 2011). Despite the managed care and cost containment trends of the
1980s, the 1990s reengineering of medical organizational structures, and the increased competition with nurse
case managers, health social workers have been creative in developing programs that positively impact patient
outcomes and help hospitals remain as viable institutions responsive to those in need (Judd & Sheffield,
2011).

Exhibit 7.5 U.S. Health Care Programs and Reforms

Source: http://en.wikipedia.org/wiki/Managed_care licensed under CC-BY-SA 3.0
https://creativecommons.org/licenses/by-sa/3.0/.

The Bureau of Labor Statistics (2014) Occupational Outlook Handbook reveals an expected 19% increase in job
growth for health social workers over the next decade. The National Association of Social Workers (in press
b) assesses that 14% of social workers practice in health-related settings, and the number is expected to
increase by 34%.

The Bureau of Labor Statistics (2014) Occupational Outlook Handbook for health care social work displays a
plethora of interesting opportunities. For example, general medical and surgical hospitals, home health care
services, individual and family services, skilled nursing facilities, outpatient care centers, psychiatric and
substance use hospitals, grant-making and giving services, health and personal care stores, specialty hospitals,
employment services, insurance carriers, and agencies, brokerages, and other insurance-related activities

316

represent but a few health care social work opportunities.

One area of growth is in clinical social work, whose practitioners collaborate with other health care
professionals to diagnose and treat medical, mental, behavioral, and emotional issues. Because of relatively
short lengths of hospitalization, more social workers are employed in outpatient rather than inpatient health
care settings (Bureau of Labor Statistics, 2014).

To have a successful career in health social work, it is helpful to have

Knowledge of medical terminology.
Understanding of the roles of all health care team members.
Understanding of the biopsychosocial-cultural and spiritual aspects of illness and health.
Crisis intervention skills.
Short-term counseling skills.
Knowledge about culturally competent planning and discharge planning processes and community
resources.

When health social workers interview people, assess family situations, and document information, they use
vernacular specific to the context within which they are employed. For example, clients are generally called
patients in hospitals, persons in home health care, and residents in long-term care.

Prospective health social workers must also make sure they have dealt with their own fears of and issues
surrounding illness and death with a strong family member, colleague, or friend beforehand. It is challenging
to lose a young cancer patient or even an elderly patient with whom one has shared the emotional experience
of dying. While health social work can be stressful, these professionals often serve as the “glue” for a health
care team.

Summary

Life is stress and stress is life.

Hans Selye

Illness is a normal part of life; everyone gets sick at one time or another. Illness is usually felt somewhere in the body, but viruses
such as tuberculosis and HIV may go undetected and be passed from person to person through the air or physical contact. Some
illnesses come from bacteria in the environment—from food, drink, objects, people, or animals. Some illnesses result from genetic
factors, and others have unknown causes. The diagnosis of a serious or chronic illness is a life-altering experience for a person and his
or her loved ones.

When a person has no family, has trouble coping with a physical impairment, or has experienced undue pain, an injury, or suffering,
social workers can help. Social workers are found in settings that range from community nonprofit hospitals and outpatient public or
ambulatory care clinics to inpatient for-profit hospitals, transitional care rehabilitation units, assisted-living facilities, and long-term
care settings, and they can also be found through home health agency referrals.

Health care is expansive, expensive, and complex. No matter their role or context, health social workers must understand the health
care system and realize the prevalence of chronic illness in older adults, the concerns of veterans, and insurance and the implications
of the Affordable Care Act.

317

318

Top 10 Key Concepts

acute illness
chronic illness
electronic medical records (EMRs)
health disparities
hospice
integrative medicine
long-term care
pain
rehabilitation
resilience

319

Discussion Questions
1. Do Americans take good care of themselves? Explain.
2. What does it mean to be chronically ill? Consider how your body functions as a sensory body, an emotional body, a spiritual body,

an economic body, a productive body, a body of ideas and meanings, and a body in multiple garbs and spaces (wording inspired by
DePoy & Gilson, 2007, p. 267).

3. What are the goals of the Affordable Care Act? Does the law itself seem likely to achieve those goals? Why or why not? What
features are still missing? How have President Trump and the Republican majority Congress been addressing health care issues?

4. How is technology and telehealth assisting people and diminishing health disparities?
5. What have you learned about illness and health disparities in this chapter? Why are people who are poor, less educated, and

members of particular races and ethnicities more prone to certain illnesses? What can social workers do about these disparities?
6. How does health social work differ in rural versus urban parts of the United States?

320

Exercises
1. The opening vignette about health social worker Gayle identifies many practice settings where she has worked. Which of these

settings might be places you would like to work? Why?
2. Locate some family or friends who have been hospitalized recently or have a serious health problem. Ask them what concerns they

have about our current U.S. health care system, based on their own experiences or the experiences of other people they know.
3. Read about the life of Baseball Hall of Famer Lou Gehrig and the ALS that caused his early death. How did he face his illness?

What lessons can we learn from the choices he made in life and while nearing death? What do you think about his famous final
speech at Yankee Stadium?

4. How does the U.S. health care system compare with those of other countries? In what ways is it better? In what areas is there
room for improvement?

5. Look at the list of U.S. health care programs in Exhibit 7.6. Research some of the programs. Which ones are your favorites? Why?
What special health care programs exist in your state?

6. Go to the WHO website where the Top 10 causes of death are listed. How are the top 10 causes in wealthy countries different
from those in poor countries?

7. Talk with your friends and relatives who use Fitbit or another similar device to monitor their health-related habits such as
exercise, heart rate, and calorie intake. What did you learn about yourself and others in terms of health maintenance and
prevention measures?

Exhibit 7.6 Where Health Care Social Workers Practice

Online Resources

Association of Oncology Social Work (www.aosw.org): Unifies and supports psychosocial oncology practitioners with the
common mission of improving psychosocial support services for patients and families facing cancer
Center for Medicare Advocacy (www.medicareadvocacy.org): Works to ensure that older adults and people with disabilities
have fair access to health care and Medicare
Centers for Disease Control and Prevention (www.cdc.gov): Works 24/7 to protect America from health, safety, and security
threats in and outside the United States
Centers for Medicare and Medicaid Services (cms.hhs.gov): An agency within the U.S. Department of Health and Human
Services that administers several key federal health programs (see also the official U.S. government site for Medicare
information: www.medicare.gov)
Council of Nephrology Social Workers of the National Kidney Foundation (www.kidney.org/professionals/CNSW):
Provides information about working with people who have chronic kidney disease
National Association of Social Workers HIV/AIDS Spectrum Project (socialworkers.org/practice/hiv_aids/default.asp):
Offers health and behavioral health care providers education and technical assistance related to the effects of HIV/AIDS on
mental health and wellness
National Patient Advocate Foundation (www.npaf.org): A national nonprofit organization providing patients a voice in
improving access to, and reimbursement for, high-quality health care through regulatory and legislative reform at the state
and federal levels
World Health Organization (www.who.int/en): Within the UN system, responsible for providing leadership on global
health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options,
providing technical support to countries, and monitoring and assessing health trends

321

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

322

Chapter 8: Physical, Cognitive, and Developmental Challenges

Source: RJ Sangosti / Contributor / Getty Images

323

Learning Objectives
After reading this chapter, you will be able to

1. Identify three main categories of physical, cognitive, and developmental challenges, and types of challenges within those
categories.

2. Understand the importance of stigma in the lives of people with physical, cognitive, and developmental challenges.
3. Distinguish between Americans’ historical and current views of physical, cognitive, and developmental challenges.
4. Identify federal policies relevant to people living with physical, cognitive, and developmental challenges.
5. Understand why people with physical, cognitive, and developmental challenges are more likely to experience disparities in health

and health care.
6. Articulate social work roles and careers related to people with physical, cognitive, and developmental challenges.

Joe Advocates for People With Intellectual Challenges

As the administrator of The Arc (historically known as the Association for Retarded Citizens), an organization founded in 1950 by a
small group of parents and others, Joe recognizes the invaluable social work services his staff renders to families and people with
intellectual disabilities (the term that replaced mental retardation in the Diagnostic and Statistical Manual of Mental Disorders, 5th
edition, or DSM-5).

In addition to collecting community donations for The Arc’s thrift stores, his staff promotes and protects human rights and supports
the inclusion and participation of Arc clients in community life throughout their lifetimes. As Joe writes his reports, grants, and
letters to legislators, he reflects on the strong grassroots network of the 140,000 members affiliated with more than 700 state and
local chapters across the United States. When Joe drives to The Arc’s national headquarters in Washington, D.C., he spends time
continuing to educate policymakers and service providers on best practices and issues that affect people with intellectual disabilities
and their families. Joe is proud that The Arc is a national force that creates an environment in which people with intellectual
challenges and their families have choices and opportunities as they live their lives.

When Joe supervises social work students, he makes sure to emphasize the crucial role of advocacy with the executive and legislative
branches of government, administrative agencies, school districts, and other providers. Joe has students follow policies at the national
level so they can learn how to influence federal agencies and policymakers, and obtain funding opportunities for disability programs
and services (The Arc, 2014).

People with physical, cognitive, or developmental challenges are people who have individual abilities,
interests, and needs. They are mothers, fathers, daughters, sons, brothers, sisters, friends, neighbors,
coworkers, teachers, and students. Their contributions enrich our communities and society as they live, work,
and share their lives.

About 54 million Americans—1 out of every 5 individuals—have a challenge. About 15% of the world’s
population has physical, cognitive, or developmental challenges, and there is no available data for indigenous
persons with challenges (UN Enable, n.d.-a). Accidents, genetic diseases, viruses, and illnesses render many
people with special needs to a different degree. But the causes leading to special needs are more mundane
than you might imagine (see Exhibit 8.1).

Americans currently live in a rather inclusive society, yet people with physical or health-related psychosocial,
sensory, mental or psychiatric, cognitive or learning, neurological, or intellectual and developmental challenges
still experience a reality that often includes limitations, stigma, discrimination, abuse, poverty, and loss of
dignity. Historical mind-sets partly explain this behavior. For example, many colonial Americans shunned

324

people who had cognitive or physical difficulties; family members hid their relatives who were disabled. Early
documentation also reveals, however, that renowned citizens such as Thomas Jefferson, Washington Irving,
and Cotton Mather had speech difficulties, yet held formidable positions despite their physical impairments.

In corporate America today, much has changed. New laws for human rights, activism, and expanded coverage
of special needs issues have changed public awareness and knowledge. Some stereotypes have been eliminated,
but other misrepresentations persist. Consider how athletes and dancers with prosthetic legs compete on the
world stage, and how children with autism succeed in professions that require advanced degrees. Still,
however, old attitudes, experiences, labeling language, and stereotypes exist in school settings, the workplace,
health care settings, and within families.

Exhibit 8.1 Top 10 Leading Disease/Disorder Categories Contributing to U.S. Disability Adjusted Life
Years (DALYs) (2010)

Source: https://www.nimh.nih.gov/health/statistics/disability/us-leading-categories-of-diseases-
disorders.shtml.

People with physical, cognitive and developmental challenges crave accurate depictions—rather than
“inspirational porn”—that present a respectful, positive view of them as active participants in society, in
regular social, home, and work environments. People with special needs also focus attention on challenging
issues that affect their quality of life, such as accessible transportation, affordable health care, discrimination,
employment opportunities, and housing.

By virtue of the National Association of Social Workers (2008) Code of Ethics, social workers are called to
support the worth and dignity of all people—including those with physical, cognitive, and developmental
challenges. Professional social workers also run groups, develop supportive services and programs, write
grants, and advocate for the passage of legislation that benefits those living with any type of special need.
Fundamental to advancing the science of disablement is the ability to communicate across disciplines and to
speak a common language that is understood across related professional fields and disciplines (Aoki, Peters,
Platero, & Headrick, 2017; Bickenbach, Chatterji, Badley, & Üstün, 1999).

325

326

Definitions of Physical, Cognitive, and Developmental Challenges

There is no single, universally accepted definition of physical, cognitive, or developmental challenges. More
than 20 definitions of the term disability have been used for purposes of entitlement to government services,
private or public income support programs, or statistical analysis (Centers for Disease Control and Prevention,
2014c; World Health Organization, 2013). For the purposes of this book, we can say that disability is a
temporary or permanent reduction in function. However, social workers really prefer to use the asset-
promoting positive terms of physical and cognitive challenges and abilities, rather than disability, when working
with client systems.

For some people, challenge is the functional consequence of chronic cognitive or physical conditions; yet, for
others, challenges are the by-product of physical or social environments that do not accommodate people with
different functional abilities. The health condition or impairment may be visible or invisible to others, and it
may be present at birth or start at any age.

The body of law that protects people with a medical condition in the workplace also defines challenges,
frequently using the disability terminology. To be protected, a person must be qualified for the job and show
that she or he has a challenge in one of three ways:

A person may be labeled as disabled or challenged if she or he has a physical or mental/cognitive
condition that substantially limits a major life activity (such as hearing, seeing, talking, walking, or
learning). For adults, this is reflected in whether they can engage in work, and for children, this is
reflected in their ability to engage in age-appropriate activities.
A person may be labeled as disabled or challenged if she or he has a history of a chronic cognitive or
physical condition (such as cancer that is in remission).
A person may be labeled as challenged if she or he is thought to have a physical or mental/cognitive
impairment that is not transitory (lasting or expected to last 6 months or less) and is severe and
interferes with normal activities of living. The condition must have existed for at least 12 months.

327

Types of Physical, Cognitive, and Developmental Challenges

People can have different types of challenges that most laws refer to as disabilities; in this book we classify
them as developmental, physical, or cognitive. The severity of impairment varies as well. Also, people can
experience more than one disability at a time, or have co-occurring disabilities (Gargiulo, 2006). An example
of co-occurring disabilities is when a person with an intellectual challenge also has vision and neurological
impairments.

Challenges can also be defined as categorical or functional. In brief, people with categorical challenges have a
significant sensory impairment or mental illness and have developmental delays. They are likely to need long-
term care and are eligible for special education. Functional challenges limit a person’s ability to perform
physical activities, and they often can be ameliorated with assistive devices or technology.

328

Developmental Challenges

A developmental challenge is a severe chronic condition that manifests before the age of 22 and is likely to
continue indefinitely. It may occur because of a genetic predisposition or an issue before, during, or after the
person is born (DeWeaver, 1983; O’Brien, 2011). Developmental challenges are common and have increased,
requiring more health and educational services. In the United States, genetic research, in addition to policy
and practice innovations based on such research, has greatly expanded over the past few decades. A civil rights
movement associated with physical, cognitive, and developmental challenges has also expanded (O’Brien,
2011). The coexistence of these developments poses intriguing challenges for social work professionals in their
crucial role as advocates. Social workers clearly need to understand the importance of policy development
relative to challenges and biomedical concerns and proposals that have possible eugenic implications (O’Brien,
2011).

Spotlight On Advocacy

329

Dr. Temple Grandin, Autism Advocate
Now a professor at Colorado State University, writer, and inventor, Temple Grandin (2011) was born August 2, 1947. Until she was
almost 4 years old, she screamed instead of talked. Physicians diagnosed Temple as being autistic and told her parents to
institutionalize her.

In response, Temple’s supportive mother sought a second opinion, and that doctor suggested that Temple try speech therapy.
Temple’s very caring and creative mother proceeded to hire a nanny for her daughter. In 1966, Temple attended and graduated from
a New Hampshire boarding school, where she was teased horribly and called a nerd. In 1970, she earned her bachelor’s degree in
psychology from Franklin Pierce College, and then she earned her master’s degree in animal science from Arizona State University.
Temple received her doctorate degree in animal science from the University of Illinois at Urbana-Champaign in 1989.

A beautiful and informative HBO documentary titled Temple Grandin (Jackson, 2010) reveals Temple’s achievements as an animal
welfare expert as well as a staunch leader in autism advocacy movements. Temple advocates for early interventions to help address
autism and sensory issues. She also promotes having supportive teachers and mentors who can direct the fixations of children with
autistic spectrum disorders in positive and productive directions. To this day, Temple remains hypersensitive to noise and sensory
stimuli and she prefers being alone. She decided not to marry. Temple has published best-selling books on autism and humane
treatment of animals. She has also designed several creative livestock handling facilities that keep cattle calm and prevent them from
getting hurt.

Temple Grandin’s story shows how someone with the label of autism, or any other physical or mental disability, should not be
stigmatized or stereotyped as being “hopeless” or “helpless.” Fortunately, Temple had loving family members, teachers, and mentors
in her formative years who focused on her strengths and assets rather than her deficits. As a result, Temple has achieved a lot,
including fame. Temple exemplifies how the disability label of autism spectrum disorder can be transformed into an asset. In 2010,
she was listed among Time magazine’s 100 most influential people in the world, in the “Heroes” category.

1. How does Temple’s story reflect a focus on assets versus deficits for people with developmental disabilities?
2. What role(s) do family members, teachers, and health care providers play in relating to people with autism spectrum

disorders?

A combination of causes can lead to a developmental challenge being diagnosed, and genetic counselors are
experts at understanding these connections. These are some of the most commonly encountered
developmental challenges :

Autism. Autism is a neurobiological developmental disorder that generally appears before age 3 and
affects the normal development of the brain in areas of social interaction, communication skills, and
cognitive functions. People with autism may have trouble in nonverbal and verbal communication, social
interactions, and leisure or play activities. Asperger’s syndrome is now considered a part of the autism
spectrum. People with autism may be high functioning. Dr. Temple Grandin, for example, was
diagnosed with autism but has earned a PhD and made a name for herself in the areas of animal welfare
and autism advocacy.
Cerebral Palsy. Cerebral palsy is a chronic condition affecting control of the body and/or limb
movement, muscle tone, and coordination. It is caused by damage to one or more specific areas of the
brain as the brain develops. Usually, there is no damage to sensory or motor nerves controlling the
muscles. The brain change is not progressive, but the characteristics of disabilities resulting from brain
damage often change over time.
Down syndrome. Trisomy 21, commonly known as Down syndrome, is a chromosomal disorder caused

330

by the presence of an extra 21st chromosome. It is associated with some impairment of cognitive ability
and physical growth, as well as a distinctive facial appearance.
Epilepsy. Epilepsy is a brain disorder that causes a person to have recurring seizures. Epilepsy is more
prevalent than autism, cerebral palsy, multiple sclerosis, and Parkinson’s disease combined. Globally,
about 65 million people have epilepsy, and nearly 80% of cases occur in developing countries. The cause
is usually unknown; however, brain trauma, brain cancer, stroke, and drug and alcohol misuse can result
in epilepsy. Sustaining a concussion from a sports injury or having been dropped as a baby can also cause
epilepsy. It becomes more common as people age and is controllable but not curable. Epilepsy kills
thousands of people each year.
Fetal alcohol syndrome. Fetal alcohol syndrome is a pattern of physical and mental defects that develop in
some unborn babies when their mom drinks alcohol (or uses drugs) during pregnancy. It is one of the
most common causes of intellectual disability and the only one that is 100% preventable. In addition, its
lifelong effects can include growth deficiencies, central nervous system problems, poor motor skills,
mortality, malformations of the skeletal system and major organ systems (heart and brain), and problems
with learning, memory, social interaction, attention span, problem solving, speech, and/or hearing.
Facial features may include small eyes, short or upturned nose, thin lips, and flat cheeks.
Fragile X syndrome. Fragile X syndrome is the most common cause of inherited mental incapacities. It is
one of the most prevalent intellectual disabilities inherited through generations. The clinical features are
very subtle and difficult to diagnose. The impact can range from learning disabilities to more severe
cognitive or intellectual disabilities. This syndrome is a common cause of autism or “autism-like”
behaviors. Symptoms can also include characteristic physical and behavioral features, and delays in
speech and language.

Temple Grandin gives a TED Talk called “The World Needs All Kinds of Minds.”

Source: Wikimedia Commons/Flickr.com/photos/jurvetson
Prader-Willi syndrome. The most commonly known genetic cause of life-threatening obesity in children
is Prader-Willi syndrome. This is an uncommon genetic disability. It causes low levels of sex hormones,
poor muscle tone, and a constant feeling of hunger. The section of the brain that controls feelings of
fullness or hunger does not work correctly in people with this syndrome. Their overeating leads to
obesity. Babies with Prader-Willi syndrome are usually floppy, with poor muscle tone, and have trouble
sucking. Later, other signs appear. These include short stature, poor motor skills, weight gain,

331

underdeveloped sex organs, mild cognitive impairment, and learning disabilities.

332

Physical or Mobility Challenges

A physical challenge is a highly individualized condition that substantially limits one or more basic physical
activities in life (e.g., walking, climbing stairs, reaching, carrying, or lifting). A mobility impairment describes
any difficulty that limits functions of moving, in any of the limbs or in fine motor abilities. It can stem from
multiple causes and be permanent, intermittent, or temporary. The most common permanent physical
challenges are musculoskeletal impairments such as partial or total paralysis, amputation, spinal injury,
arthritis, muscular dystrophy, multiple sclerosis, cerebral palsy, and traumatic brain injury. Rates of physical
and cognitive challenges are growing due to population aging and increases in chronic health conditions,
among other causes.

These are some common forms of physical or mobility challenge:

Orthopedic problems. Orthopedic problems are diseases or defects of the muscles and bones that cause
people not to be able to move normally (Hallahan, Kauffman, & Pullen, 2012). Genetics or the results
of injury, disease, accidents, or other developmental disorders may make it difficult or impossible for
people to walk, stand, sit, or use their hands because they can’t properly move their legs, arms, spine, or
joints.
Hearing and vision problems. Both these types of physical challenges are in perception. Visual
impairment signifies a challenge in seeing. People can have a mild visual impairment and correct it with
glasses, contact lenses, or laser surgery. The vision of others cannot be corrected, and they become
functionally limited or visually impaired (“legally blind”). People’s ability to hear also varies greatly. The
term hard of hearing actually refers to people with mild to moderate hearing loss. By comparison, people
who are deaf have moderate to severe hearing loss. Any of these people may or may not identify
themselves as deaf. Two worldviews describe people with moderate to severe hearing loss: Deaf people
may be considered to have a medical problem, or they may consider themselves part of the Deaf
community, a unique cultural group whose members use sign language and emphasize strengths
(National Association of the Deaf, 2011).
Epilepsy. In addition to being known as a developmental disability, this seizure disorder is also
considered a physical challenge. A seizure may involve a sudden change in a person’s consciousness level
or sensory distortions. Epilepsy can be caused by any type of injury to or condition in the brain, such as
high fevers, infections, physical damage, or chemical imbalances. In about 70% of cases, the cause
remains unknown.

333

Mental/Cognitive Challenges

A neurocognitive impairment is an encompassing term to describe any neurocognitive characteristic that
blocks the cognition process. The term may describe deficits in specific cognitive abilities, global intellectual
performance, or drug-induced cognitive/memory impairment, such as from alcohol, glucocorticoids, or
benzodiazepines. Neurocognitive impairments may be congenital or caused by environmental variables such as
brain injuries, neurological disorders, or mental illness. Although a neurocognitive challenge is usually not
visible, it is as legitimate an impairment to functioning as a physical disability is. Neurocognitive impairments
include the following:

Intellectual Disabilities/Challenges. Intellectual challenges, or intellectual disabilities—as they are
referred to in the DSM-5—are a disorder characterized by significant limitations both in intellectual
functioning and in the ability to adapt to circumstances, or adaptive behavior. The term intellectual
disabilities is now used to describe the same population of individuals who were diagnosed previously
with mental retardation. Every person who was eligible for a diagnosis of mental retardation is eligible
for a diagnosis of intellectual disabilities. These disabilities or challenges vary in level, type, duration,
and degree of need for individualized services and supports. Intellectual disability ranges from mild (IQ
50–70) to moderate (IQ 35–49) to severe (IQ 20–34) to profound (IQ below 20), as measured by the
Wechsler Intelligence Test.
Learning differences. Learning disabilities or differences are neurological disorders that can make it
difficult to acquire certain academic and social skills. They are not the result of poor intelligence or
laziness. Well-known learning differences include dyslexia (hinders reading, writing, and spelling),
dyscalculia (hinders math), dysgraphia (hinders writing, spelling, or putting thoughts to paper),
dyspraxia (affects motor skill development), poor executive functioning (governs one’s ability to plan,
organize, and manage details), and attention-deficit hyperactivity disorder. Learning differences do not
disappear with time.
Traumatic brain injury. Traumatic brain injury usually results from a violent blow to the head or body,
or when an object, such as a bullet, penetrates the skull. Such an injury can have wide-ranging physical
and psychological effects due to damage to the brain. Some symptoms may appear immediately after the
traumatic event, while others may appear days or weeks later (Mayo Clinic, 2014).

Social Work in Action

334

Iris Counsels a Family About Concussions in Sports
Iris works on the rehab floor of the local teaching hospital. Tom, a high school athlete, now a junior, is one of her newly assigned
clients whom she recently met and assessed. Later this afternoon Iris is scheduled to meet with Tom’s parents, sister, and
grandmother.

Tom told Iris that he lives for football. But he experienced his second moderate concussion during the Thanksgiving Day game. He
feels nauseous and dizzy. Not to be deterred by his injury, Tom is motivated to recover and plans to continue playing football
because he has always dreamed of obtaining a scholarship to play football in college.

Iris feels a bit anxious about talking with Tom’s family, because she is aware of the serious consequences of sports injuries across the
life course and doesn’t want to dash Tom’s dreams. She plans to share with Tom and his parents an article about concussions she
read in a medical journal (DeKosky, Ikonomovic, & Gandy, 2010). It referred to the National Football League’s creating a poster to
be hung in league locker rooms, warning players of possible long-term health effects of concussions. It also cited how public
awareness has been elevated due to the pathological consequences of traumatic brain injuries linked to high-contact sports and car
crashes. Iris has also watched the Hollywood feature film entitled “Concussion” and recalls how the film vividly portrays the
traumatic aftereffects for injured professional football players and their saddened loved ones.

Iris is going to mention the film and reinforce the article’s recommendation that Tom and his family keep an accurate diary of his
day-to-day progress in rehabilitation and his concerns with his physical and mental health over time. The diary will not only improve
Tom’s and his family’s understanding of this chronic condition but also provide Tom’s doctors with additional insights into
traumatic brain injury.

1. What websites and community resources might Iris need to locate to best counsel Tom and his family?
2. How might Tom and his family be feeling?

Time to Think 8.1

Neurocognitive impairments not only affect the person with the challenge; they also have substantial influence on other family
members. Imagine that one of your family members had a neurocognitive challenge. How might your family member’s
neurocognitive challenge affect you?

335

Stigma and Discrimination Against People With Physical, Cognitive, and
Developmental Challenges

People with physical, cognitive, and developmental challenges experience discrimination and injustices.
Sometimes the discrimination is subtle and unconscious, as when people talk over the head of an individual in
a wheelchair. Other times the prejudice and discrimination is blatant and intended. On a social level, people
with physical and mental challenges are often overlooked. For example, they are seldom recognized as a group
to be included in a national response to HIV/AIDS, and they are likely to be neglected or abandoned during
evacuations in disasters and conflicts due to lack of preparation, planning, and transportation systems.

Discrimination is often due to social stigma, which is generally a “stain” on the way a person is perceived that
leads him or her to be shunned by others. A famous 20th century sociologist, Erving Goffman (1963), noted
that “stigma is a process by which the reaction of others spoils normal identity.” Goffman identified three
forms of social stigma:

Visible or outer deformations such as scars, a cleft lip, or obesity—physical or social disabilities
Deviations in personal traits, such as mental illness, alcoholism, drug addiction, or having a criminal
background
Imagined or real traits of an ethnic group, nationality, or religion that are thought to deviate from the
prevailing norm, or “tribal stigmas”

Regardless of the form of social stigma, the stigmatized person is subjected to discrimination and loses status.
Stigmatization can occur at work, in health care, in educational settings, in the criminal justice system, and in
one’s own family.

Social workers who work with people who have special needs have observed how stigma affects the behavior
of people who are stigmatized. For example, by age 10, most children are aware of disability stereotypes, and
children who are members of stigmatized groups are aware of the stereotypes at an even younger age. People
who are stereotyped and stigmatized because of their challenges begin to act the way that the people who are
stigmatizing them expect them to act. Stigma can also shape people’s beliefs and emotions, leading them to
feel depressed or have low self-esteem.

Time to Think 8.2

What are your thoughts about Americans’ views of physical, mental/cognitive, and developmental challenges then and now?

Suppose you had either a visible or invisible special need. Would you disclose this information during a job interview?

If you possess a physical, mental/cognitive, or developmental challenge, is that a source of encouragement or discouragement for
entering a helping profession? Why or why not?

336

337

Social Work With People Living With Physical, Cognitive, and
Developmental Challenges

Most people will have a physical or cognitive challenge in their lifetime. Often that challenge or special need
will last for a short time, but some people live with developmental, physical, or mental/cognitive challenges for
a long time. Any of these people may require a social worker to help them navigate services, resources, and
health care.

338

Historical Background of Services for People Living with Physical,
Cognitive, or Developmental Challenges

Historically, people with special needs have been regarded as people to be pitied, feared, or ignored. They
have been portrayed as helpless victims, repulsive adversaries, heroic individuals overcoming tragedy, and
charity cases who must depend on others for their well-being and care. Media coverage frequently focuses on
heartwarming features and inspirational stories that reinforce stereotypes, patronize, and underestimate
people’s capabilities (Keller & Hallahan, 1990). Consider some of the contestants on the popular American
television show “Dancing With the Stars”—Nyle Dimarco and Terra Jole.

The historical roots of today’s attitudes toward physical, cognitive, and developmental challenges help explain
why those attitudes are so complex today. Indigenous North Americans had no concept of disability or
challenges (Nielsen, 2012). The Europeans who established the colonies, however, did have the concept that
physical and cognitive differences required intervention. The Europeans also brought new diseases to the
continent, which created more physical and mental/cognitive infirmities that they defined as disabilities.

The colonists also introduced the notion that those who were challenged and unable to work, along with
children and newcomers, should not be punished for failing to observe some of the laws (Nielsen, 2012).
Although people with intellectual challenges were often abused and exploited, as they are today, people with
challenges were also cared for—mostly by families, although people with physical and mental challenges
became a community responsibility if they were poor and could not be adequately controlled by their families.
Of course, as is the case today, the treatment of people with physical and mental challenges depended a great
deal on socioeconomic status, race, and gender.

During the 1840 census, people began debating society’s role in taking care of people with challenges, and
race was a complicating factor (Nielsen, 2012). After the Revolutionary War, the approach to disability
changed dramatically. Disability began to be explained as a biological matter. People considered those with
epilepsy to be “idiotic” or insane, and heavy drinkers—along with people considered morally suspect, such as
unmarried pregnant women—were often sent to almshouses, prisons, and asylums.

All people need opportunities to succeed.

Source: ©iStockphoto.com/Fat Camera

Treatments were sometimes gruesome, including “purging, bleeding, frights, hard labor, and immersion in
cold water” (Nielsen, 2012, p. 38). After visiting some of the indigent and mentally ill people in

339

Massachusetts, Dorothea Dix began advocating for reform. She found that people with intellectual challenges
and mental illness were sometimes penned up with criminals, sometimes chained and naked. The facilities
were not always heated in winter, and the residents were abused, beaten, and not given adequate food.

Once the industrial revolution got under way, in the 1890s and beyond, the needs of people who acquired
various physical and cognitive challenges due to workplace accidents and exposure to harmful substances
increased dramatically:

Textile mill operatives lost fingers, hands, and arms due to rapidly moving machinery. . . .
Boilermakers, shipbuilders, and train engineers often lost hearing due to their noisy surroundings.
Clock and watch painters, most of them female, experienced the paralysis and mental debility
caused by lead poisoning as well as throat and mouth cancer. (Nielsen, 2012, p. 127)

In the late 1800s and early 1900s, the Progressive Era, new understandings of blindness and deafness led to
reforms of institutions that housed some of the “disabled,” and they experienced some measure of acceptance
and empowerment (Nielsen, 2012). In contrast, people with intellectual challenges and mental health issues
still were warehoused in bleak circumstances.

During World War I, adaptive technologies were developed for soldiers who experiencing physical and
cognitive challenges (Nielsen, 2012). World War II brought new technologies, as well as a new cadre of
rehabilitation experts.

People with physical, developmental, and cognitive challenges began to be treated much more sensitively
during and after the Great Depression (Nielsen, 2012). The League of the Physically Handicapped was
formed and began promoting the idea that people with physical, developmental, and cognitive challenges are
entitled to the full rights of citizenship.

340

Deinstitutionalization

In the 20th century, as the horrors of some institutions for people with challenging conditions became better
known, some reformers began advocating deinstitutionalization, or the removal of people with physical and
mental challenges from institutions and their better integration into the community. From 1965 to 1980, as
the idea of deinstitutionalization took hold, public asylums lost about 60% of their inmates (Nielsen, 2012).

With the civil rights movement of the late 1960s, people with physical and cognitive challenges, along with
their friends, family members, and professionals, endeavored to change the view that a person with a chronic
illness or physical/cognitive/developmental challenge will always be unable to cope independently with life.
The civil rights movement argued that just like other minorities, people with special needs are disadvantaged
as much by discrimination as by their physical limitations, or more (Gliedman & Roth, 1980; Scotch, 1988).
Many asylums and other institutions were closed, and their residents were sent home to enjoy life on their
own. Independent-living centers began to appear in the late 1960s and espoused the principles of self-
determination and deinstitutionalization. They are community agencies, usually staffed by people with
challenges, who use peer counseling and advocacy to help others live on their own. A distinct culture and
philosophy resulted from this independent-living movement and now exists around independent-living
centers.

Current Trends

341

Confronting Stigma
Most people with physical and cognitive challenges are well aware of the way other people perceive them. They understand stigma
and discrimination. In the past few decades, however, people living with such challenges, as well as the people who love, support,
and champion them, have developed some interesting—and even fun—ways to try to overcome stigma.

Sports for people with special needs is one well-known activity that can help reduce stigma and discrimination. The Special
Olympics, a movement founded in 1968, is now global. Its mission is to provide year-round sports training and athletic competition
through “Olympic-type sports for children and adults with intellectual challenges, giving them continuing opportunities to develop
physical fitness, demonstrate courage, experience joy and participate in a sharing of gifts, skills and friendship with their families,
other Special Olympics athletes and the community” (Special Olympics, 2014). Other examples include the Paralympic Games and
wheelchair basketball for people with physical challenges. Sports are an excellent platform for strategies of inclusion and adaptation
because they have the unique ability to transcend linguistic, cultural, and social barriers. Sports and top athletes of all kinds are also
universally popular. Concordia College’s Social Work Club, for example, has participated in area Special Olympics (Taylor, 2012).

1. How might seeing people with intellectual challenges participating in sports serve to put them in a new light for people who
tend to stigmatize them?

2. Social workers are eligible to become members of the Special Olympics Global Scholars delegation, which allows them to
travel internationally with people who have special intellectual needs. What interest might you have in becoming involved
with such a delegation?

Art created by people with physical or mental challenges also helps break down stigma. People with intellectual challenges are often
encouraged to create paintings, sculptures, and other objets d’art, some of them highly sophisticated interpretations of the world.

Another interesting artistic effort was a documentary film on artists with challenges, called Shameless: The Art of Disability (Klein,
2006). The project was organized by an established director who experienced a debilitating stroke. She gathered a group of five
artists with special needs for a pajama party, where they identified some of the common stereotypes of people with challenges in film
and fiction (e.g., The Monster, The Saint, The Psycho, The Poor Little Crippled Girl). The artists made a pact to meet a year later
at the KickstART Festival to present their own images of disability. The resulting film was praised as humorous, energetic, honest,
and vulnerable. As the film tracks these artists, viewers come to recognize their passion for art and understand the everyday
complexities and richness of life that was different but complete.

However, in the 1970s and 1980s, professional caregivers, advocates, and decision makers were already
beginning to realize that deinstitutionalization was leaving some physically or cognitively challenged persons
without enough support (Logsdon-Breakstone, 2012). Only the privileged or lucky few were able to be
housed in independent-living centers, community-based mental health centers, or group homes. The rest were
being left to fend for themselves on the streets or were incarcerated. Today, people who have intellectual and
mental challenges and who lack the resources for professional care most often end up in jail or prison.

However, in 2009 the Department of Health and Human Services created the Community Living Initiative.
The initiative developed and implemented innovative strategies that increase opportunities for Americans
with special needs and older adults to enjoy meaningful community living. The Affordable Care Act (ACA),
signed into law in 2010, expands the scope of the initiative and helps U.S. states promote and support
community living for people with special needs. Conversely, changes to the ACA offered by President Trump
and predominantly Republican members of the U.S. Congress could drastically reduce medical benefits or
dramatically increase insurance premiums for people with pre-existing conditions, including people receiving
Medicaid and/or with physical and mental challenges. In 2017, the American Health Care Act (AHCA), was
proposed, which would have likely delivered private markets over bureaucratic edicts and supported a more

342

gradual reduction in the future growth of Medicaid. However, the fate of this type of proposed legislation is
uncertain.

Dorothea Dix advocated for the rights of the mentally ill.

Source: Library of Congress, Prints and Photographs Divison, LC-USZ62-123278

343

Americans With Disabilities Act

In 1990, the Americans with Disabilities Act (ADA) was passed. It was written to protect persons with
challenges from discrimination based on stigma. The ADA defines disability as any physical or
mental/cognitive challenges that substantially limit one or more major life activities such as caring for oneself,
performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, or working.

Enforcement of the ADA is handled on a case-by-case basis. People are not entitled to protection under the
ADA simply because they have been diagnosed with a special need. The challenging condition must
substantially limit their ability to perform major life activities. The ADA uses a four-stage framework to
categorize the level of difficulty experienced by an individual, ranging from least to most severe (Cornell
University, 2013; Jette, 2006; Masala & Petretto, 2008):

1. Pathology
2. Impairment
3. Functional limitation
4. Disability

Multiple physical, mental/cognitive, and developmental challenges are covered by the ADA. Following is a
partial list of these: (1) physical, sight, speech, or hearing impairments; (2) epilepsy; (3) muscular dystrophy;
(4) multiple sclerosis; (5) cancer, heart diseases; (6) diabetes; (7) HIV or AIDS; (8) cognitive disabilities; (9)
psychiatric disabilities; (10) specific learning disabilities; (11) developmental disabilities; and (12) recovered
drug or alcohol addiction.

The law places strict limits on employers when it comes to asking job applicants to answer medical questions,
take a medical exam, or identify a challenging condition:

After a job is offered to an applicant, the law allows an employer to condition the job offer on the
applicant answering certain medical questions or successfully passing a medical exam, but only if all
new employees in the same type of job have to answer the questions or take the exam.

Once a person is hired and has started work, an employer generally can only ask medical questions
or require a medical exam if the employer needs medical documentation to support an employee’s
request for an accommodation or if the employer believes that an employee is not able to perform a
job successfully or safely because of a medical condition.

The law also requires that employers keep all medical records and information confidential and in
separate medical files. (U.S. Equal Employment Opportunity Commission, 2014)

344

345

Social Work Practice With Physical, Cognitive, and Developmental
Challenges

Social workers who specialize in knowledge about physical, cognitive, neurocognitive, or developmental
challenges may end up working in a hospital, mental health organization, supportive rehabilitative services,
vocational rehabilitation, an employee assistance program, resettlement programs for refugees, sports clinics,
HIV/AIDS clinics, disaster relief, the military, or residential treatment centers. Social workers observe how
physical, emotional, or cognitive disabilities alter the lives of people they serve.

Social workers can make a significant difference in the lives of children with special needs.

Source: ©iStockphoto.com/Steve Debenport

Because social workers tend to learn about physical and cognitive challenges just at the time their clients are
doing the same, they have come to view such challenges as rather stressful, where a sudden crisis turns into
protracted, irremediable problems, strains, and disappointments. Social workers who help serve clients while
under stress are encouraged to adopt the following practice behaviors (Mackelprang & Salsgiver, 2009; May
& LaMont, 2014):

Be person centered and involve people with physical and cognitive challenges in decision-making
processes that directly affect their lives.
Facilitate access and respect in a person’s environment.
Focus on helping the person and his or her support system cope well with challenging situations.
Incorporate a strengths-based and resilience-oriented perspective to build on the person’s inherent
strengths and resources.

Person-First Language

Another way social workers can better serve their clients is to be careful about the terminology they use.
Because words are very powerful, the language we use to refer to people with physical, mental, and
developmental conditions shapes our beliefs and ideas about them. Old, inaccurate, and inappropriate
descriptors perpetuate negative stereotypes and attitudinal barriers. When we describe people by their labels or
medical diagnoses, we devalue and disrespect them as people. In contrast, if we use thoughtful terminology,
we can foster positive attitudes about people with physical, mental, or developmental challenges. One of the
major improvements in communicating with and about people with special needs is person-first language,
which emphasizes the person, not the challenging condition. For example, we refer to a “person with a special

346

need” rather than “a disabled person.” Saying our client is “living with schizophrenia” is more empowering
than saying “our schizophrenic client.” Instead of describing a person as “wheelchair-bound,” we could say
that he “lives with a mobility challenge” or is a “person who requires a wheelchair.” By placing the person first,
the physical or cognitive challenge is no longer the primary, defining characteristic of the individual but just
one of several aspects of the whole person. Person-first language is an objective way of acknowledging,
communicating, and reporting on a condition. It eliminates generalizations and stereotypes.

The terminology used to refer to individuals with challenges, as well as to the challenging conditions
themselves, has also changed. Social workers avoid using the following terms: birth defect, deaf and dumb, fits
(epileptic seizures), retarded, stupid, normal, cripple, handicapped, invalid, victim, insane, crazy, lunatic, and
mental patient.

Time to Think 8.3

How do the words others use to describe you influence your life? To what extent do you think that language shapes attitudes and
attitudes drive our actions?

What do you think about the concept of person-first language? Why should we avoid calling all people with challenges
“inspirational”?

Services for Persons With Physical, Cognitive, and Developmental
Challenges

As direct service providers, social workers are advocates, educators, clinicians, facilitators, group leaders, and
program developers, and are employed in for-profit, nonprofit, and public programs intended to serve people
living with special needs. Social workers assess severity levels of needs in clients who present with a chronic
medical condition or physical, cognitive, or developmental challenges. Social workers engage in therapy
groups; care management; assessment/information/referral services; individual or self-advocacy initiatives to
address education, employment, health care, and other concerns; residential support; family support;
employment programs; and leisure and recreational programs. Because people with physical, cognitive, and
developmental challenges also seek social services for situations not specific to issues presented by their
impairments, a generalist social work approach to practice is very applicable.

Social workers can also help their clients with four specific issues relevant to their condition:

Civil rights. Many clients with special needs are protected by five particular acts that acknowledge the
civil rights of people with challenges. Exhibit 8.2 outlines these acts. Social workers who are familiar
with the provisions of these acts will be more effective advocates for clients.
Income support. Many people living with physical, cognitive, and developmental challenges cannot earn
enough through a job to support themselves financially. They are often eligible for income support.
Public assistance may also be available. Since 1950, when a fourth public assistance program titled Aid
to the Disabled was added to the Social Security Act of 1935, federal and state governments have been
able to provide assistance to the needy, blind, aged, and totally disabled through the Supplemental
Security Income program. In addition, the Social Security Disability Insurance program provides long-

347

term income support to workers whose special needs prevent them from working, no matter the cause of

their challenges. Disability Insurance, workers’ compensation, and Supplemental Security Income fall
under the category of income support.
Education and rehabilitation. A multitude of education and rehabilitation services are available to people
with physical, developmental, and cognitive challenges. Through the Rehabilitation and Services
Administration, grants are distributed that help people with physical and cognitive challenges get work
and live by themselves, as they are provided with supportive counseling services, medical and
psychological assistance, job training, and individualized assistance. Also, clients who are older adults,
have a documented challenge, or are determined to be legally blind may be eligible to receive
Supplemental Security Income. The maximum monthly federal payments to these recipients in 2014
were $721.00 for an individual, $1,082.00 for a couple, and $361.00 for an essential person. Exhibit 8.3
indicates the types of services available to people with challenges and their funding sources.
Genetic counseling. Social workers can serve individuals or families as genetic counselors in hospital-based
and other settings. Genetic counseling provides information and support to people who have, or may be
at risk for, genetic disorders such as sickle cell anemia and Down syndrome. They may also counsel
individuals whose illness or condition is based on lifestyle and environment, as with colon cancer. People
may seek genetic counseling if they (1) have a personal or family history of a genetic condition or birth
defect, (2) are pregnant or planning to be pregnant after age 35, (3) already have a child with a genetic
disorder or birth defect, (4) have had two or more pregnancy losses or a baby who died, or (5) have had
ultrasound or screening tests that suggest a possible problem. The National Society of Genetic
Counselors (n.d.) advocates for improved access to quality genetic counseling and works to ensure that
this profession is a recognized and integral part of the health care system. Genetic counseling is
effectively accomplished by social workers who focus on psychological and social adjustment. Social
workers need to know about the Human Genome Project, genetic testing, the biology of genetic
inheritance, psychosocial counseling, values and ethics, and social policy in genetics (Mealer, Singh, &
Murray, 1981; National Association of Social Workers, in press b; O’Brien, 2011; Schild & Black,
1984; Taylor-Brown & Johnson, 1998).

Exhibit 8.2 Civil Rights Protections for People With Challenges/Special Needs

Source: Adapted from Asch and Mudrick (1995, p. 758, Table 5).

Exhibit 8.3 Federal, State, and Local Funding for Disability Services

348

349

Diversity and Physical, Cognitive, and Developmental Challenges

More than a billion people, or about 15% of the world’s population, have some form of physical, cognitive, or
developmental challenge. While some health conditions associated with such challenges result in poor health
and extensive health care needs, others do not. Of course, some of the variation in independence among
people with disabilities can be attributed to varieties of difference.

Social Work in Action

350

Jade Develops a Transition Plan for a Young Adult With
Developmental Disabilities
Jade’s social work position with people who have special needs requires that she know how to develop treatment plans and
individualized education plans. She must also be cognizant of the biopsychosocial features of multiple intellectual challenges and
developmental abilities and co-occurring physical and cognitive conditions. As skilled as she is, Jade is challenged to help Colin, and
his family, given the limited amount of time she can spend with the client system.

One of Jade’s clients is Colin, a 17-year-old male attending some classes at a special services center and some classes at high school
in the local county school district. He is currently enrolled in a transition program designed to help students transition from the
traditional high school program into the adult world at age 21. He also works in the cafeteria, preparing and serving food. The
transition program helps instill a strong work ethic in students and encourages independence and social skills development. Colin
also enjoys playing video games. At the center, he participates weekly in a group experience and receives one-on-one counseling with
Jade.

However, Colin is diagnosed with autism, lacks good socialization skills, and trusts no one. He rarely makes eye contact and tends to
avoid others. His family fears him because he is sometimes very aggressive. One goal in Colin’s treatment plan is to reduce the
amount of times he says, “I want to kill you,” “I want to die,” and “I don’t want to go home.” A second goal is to match Colin with a
mentor so he can potentially learn to trust one person and receive cognitive behavioral interventions. A third goal for Colin is to
graduate from high school. Jade has also prepared an individualized education plan for Colin to ensure that his educational needs are
met. Because Colin is 19, he has been informed of his rights upon completion of the transitional program within the high school.
Only if he still requires more behavioral skills to function adequately in the outside world will he be able to stay for an additional
year.

The ADA relates to Colin’s case. A variety of accommodations are required for Colin to adequately function at home and in groups.
One accommodation at school is a scheduled break, because Colin is also diabetic and must eat properly to maintain his blood sugar
and insulin levels.

1. How would you intervene if you were Jade?
2. How ready might Colin be to get his driver’s license?

Age. Some children with more severe challenges or special needs are not enrolled in school. Also,
adolescents with physical, cognitive, or developmental challenges are more likely than children without
challenges to be excluded from vital sexual and reproductive health education programs. Adults with
differing abilities have a 400% elevated risk of developing Type 2 diabetes. Diabetes is also highly
correlated with vision loss (Yee, 2011). The aging process for some groups of people with disabilities
begins earlier than usual. For example, some people with developmental challenges show signs of
premature aging in their 40s and 50s.
Class. For people who can pay for assistive technology, such devices can help people with learning
differences leverage their strengths and work around or compensate for learning problems, which is key
to increasing independence in school and throughout life. All people with physical, cognitive, and
developmental challenges have the same general health care needs as everyone else, but they differ in
socioeconomic status that dictates insurance resources.
Race and ethnicity. Indigenous people with physical and cognitive challenges or special needs experience
multiple forms of discriminations and face barriers to the full enjoyment of their rights, based on their
indigenous status and also on disability. African American adults have higher morbidity and experience
challenges earlier in life compared with white adults; however, when socioeconomic resources, social

351

integration, and other health indicators are adjusted for, the trajectories of special needs by race are not
significantly different over time (Kelley-Moore & Ferraro, 2004). See Exhibit 8.4 for a breakdown of
how physical and cognitive challenges affect different racial and ethnic groups.
Gender. Women with physical or cognitive challenges and special needs receive less screening for breast
and cervical cancer than do women without similar challenges. (For that matter, people with intellectual
impairments and diabetes are less likely to have their weight checked.) Women with mobility difficulties
are often unable to access breast and cervical cancer screening because examination tables are not height
adjustable and mammography equipment accommodates only women who are able to stand. Women
with physical/cognitive challenges or special needs face more public and private difficulties in attaining
adequate housing, health, education, vocational training, and employment, and are more likely to be
institutionalized. Women and girls with physical, cognitive, or developmental challenges also experience
higher risk of gender-based violence, sexual abuse, neglect, maltreatment, and exploitation. The global
literacy rate is as low as 1% for women with disabilities (UN Enable, n.d.-b).

Durable medical equipment helps people successfully navigate the world around them.

Source: iStock Photo / fstop123
Sexual orientation. People who identify as lesbian, gay, bisexual, transgender, intersex, questioning, or
asexual feel marginalized within two communities when they also have a special need or
physical/cognitive challenge. One factor links the two realms of difference: The sexual orientation of
men and women is not always visible; similarly, oftentimes physical, cognitive, or developmental
challenges are not visible (e.g., learning difference, traumatic brain injury, multiple sclerosis).
Intersections of diversity. As in other areas of need, multiple dimensions of difference further complicate
the lives of those with physical, cognitive,, or developmental challenges. Consider gender and age. As
Exhibit 8.5 shows, in all age groups women report more challenges than men do. There are several
reasons for the differences reported, but notice also that reported disability rises with age. As a result,
women 65 and up are more than 5 times more likely to be physically or cognitively challenged than are
men 18 to 44. Women are more prone to conditions such as arthritis, depression, and osteoporosis
because they live longer than men and consequently survive to ages at which challenging conditions are
more common. A woman who dies at 85 has a longer period of needing accommodations than a man
who dies at 85. Typically, women with physical or cognitive challenges no longer have husbands to take
care of them. Also, with aging come increased problems with mobility, and if people become overweight
or obese they are at increased risk for developing potentially chronic conditions such as heart disease,
Type 2 diabetes, high blood pressure, stroke, osteoarthritis, respiratory problems, and some forms of

352

cancer.

Exhibit 8.4 Physical, Cognitive or Developmental Challenges Across Race and Ethnicity in the United
States

Source: Centers for Disease Control and Prevention (2008).

*Aged 18 years or older

353

Advocacy on Behalf of People With Physical, Cognitive, or Developmental
Challenges

In the United States, people living with physical, mental/cognitive, or developmental challenges who have
been successful in their fields and careers are heralded as advocates, pioneers, and role models. Places such as
Gallaudet University (for the deaf and hearing impaired), youth summer camps, and Special Olympics venues
empower people to dream, achieve, and hope for a positive future.

Social workers who work with people who have physical, mental/cognitive, or developmental challenges must
help them focus on their assets and advocate for cultural and policy changes that value people no matter their
challenge or impairment. If people with a range of physical or cognitive challenges could figure out how not to
isolate themselves but instead unite as one, they would be a powerful lobbying force to be reckoned with on
Capitol Hill and in the media.

Professional social workers who find themselves working in settings with people with a wide range of physical
and cognitive challenges must be educated advocates who can teach others about how individuals,
organizations, and government agencies continue to use the disability terminology and define disability in so
many different ways. Social work advocates require understanding of how challenges can be the result of an
acute or chronic medical, physical, or cognitive condition for some, and for others could manifest as a by-
product of physical or social environments, or be a functional consequence of a chronic physical impairment or
cognitive condition.

Social workers can connect people living with physical, cognitive, or developmental challenges to relevant
services and resources, including rehabilitation services, employment services, public education, psychiatric
care, disability insurance, income support, workers’ compensation, and Supplemental Security Income.
Competent social workers will understand the provisions of the ADA and connect people with health
insurance, transportation, and more.

Exhibit 8.5 Challenges By Sex and Age Group in the United States

354

Source: Centers for Disease Control and Prevention (2011b).

355

Economic and Social Justice

Since the deinstitutionalization movement and the technological advances in vision care, hearing devices,
prosthetics, orthopedics, and more, people with physical and cognitive challenges or special needs have more
choices for recovery or adjustment than ever before. However, accessing such services is still limited by
economic realities and injustices inherent in a marketplace-based system of care. When living with a
challenging physical or cognitive condition of any type, people may need equipment, devices, respite care,
acute care, or chronic caregiving assistance. These services are covered by the insurance industry and the law
but with limits. The social work profession must serve as a “watchdog” as the private, for-profit sector
commands an increasingly government-unsupervised role in delivering health care and services in both
institutional and community-based settings (Reisch, 2000).

Some countries do not provide accommodations for those with physical challenges.

Source: iStock Photo / oneclearvision

An important aspect of social and economic injustice toward people with special needs is stigma and
discrimination in the workplace. People with physical, cognitive, or developmental challenges are often unable
to support themselves financially. To be successful advocates for such clients, social workers must be cognizant
of relevant policies. Stigma and/or scapegoating may keep a qualified individual from being hired or treated
fairly.

However, the law requires an employer to provide reasonable accommodation to an employee or job applicant,
unless doing so would cause significant difficulty or expense for the employer (“undue hardship”). The law
also protects people from discrimination based on their relationship with a person with a special need.. For
example, it is illegal to discriminate against an employee because her husband has a particular challenge (e.g.,
disability). The law forbids discrimination when it comes to any aspect of employment, including hiring,
firing, pay, job assignments, promotions, layoff, training, fringe benefits, and any other term or condition of
employment (Waterstone, 2014).

356

Supportive Environment

People with physical, cognitive, or developmental challenges often face an uncaring environment with few
public accommodations that would allow them to participate more fully in the community. Uneven access to
buildings (hospitals, health centers), inaccessible medical equipment, poor signage, narrow doorways, internal
steps, inadequate bathroom facilities, and inaccessible parking areas create barriers to health care facilities.

Private companies are becoming increasingly involved with the physical and cognitive challenges and special
needs of people. Institutional living has largely been replaced by residential arrangements that accommodate
individuals’ needs, thereby increasing independence and freedom of choice. In ordinary residential areas, more
special services areas are being provided.

Professional social workers may best maximize client self-determination and service provision for all people by
being consumer centered, acquiring knowledge about resources and agency services, and advocating for the
rights of people across practice levels. Social workers empower individuals best when they attune to what the
client wants and refrain from making assumptions or labeling. Because policies that relate to people with
challenges often change, an effective social worker who works with them will be aware of laws, statutes, and
local, state, and federal regulations. The National Association of Social Workers regularly updates its
published statement that highlights the promotion of self-determination in working with people who have
challenges. When clients with special needs require more services than are available, social work advocates can
work with the power players to have services expanded.

357

Human Needs and Rights

Institutionalization can be individually devastating, because residents not only lose most of their freedom but
may be actively deprived of their civil rights and even abused (in the past especially). But institutionalization
has been influenced more by economic factors than political ones. When families found it difficult to care for
their family members, institutions became an option. Between 1880 and 1900 the
intellectually/developmentally disabled population institutionalized rose from a little over 4,000 to 15,000.

When it comes to advocating for people’s right to self-determination and ability to access appropriate health
care or services, social workers would do well to attend equally to needs and rights. Giving clients and their
families support and listening to their stories are essential components to understanding what services will be
required and sharing the process of obtaining those services.

Members of stigmatized groups start to become aware that they are not being treated equally and know they
are probably being discriminated against. For example, increasing numbers of people categorized with
intellectual challenges, especially young adults, are indeed strengthening their resistance to being viewed as
passive receivers of care.

358

Political Access

The words and the meanings Americans use in everyday life create attitudes, influence feelings and decisions,
drive social policies and laws, and ultimately affect people’s daily lives. Words matter. Using a diagnosis as a
defining characteristic reflects prejudice and also robs the person of the opportunity to define him- or herself.
Politically correct person-first language puts the person before the condition and describes what a person has,
not who a person is.

Because politics is inextricably involved when helping people with physical, cognitive, or developmental
challenges, you may choose to become a social worker involved in policy development.. By doing so, you may
help update or craft brand new policies for corporations that address a range of people. Further, you may
lobby to pass certain laws or create and write the actual laws. As a social worker you could advocate for and
with people with special needs and investigate discrimination cases or help file discrimination lawsuits.

Social Work in Action

359

Mike Learns His Responsibilities at a Residential Facility
Mike has found employment at a community-based residential facility. Clients Mike works with are people who have developmental
and intellectual challenges. During orientation week he got a sense of what his responsibilities would be:

Outreach for persons with developmental and physical challenges in both residential facilities and private homes, where he
would teach daily skills such as how to build self-esteem, how to budget and manage finances, and how to be assertive.
Respite care for parents of children with special needs, taking turns with other social workers to relieve the parents now and
then and allow the parents to replenish themselves.
Leadership of support groups for parents of children of all ages and older adults who are living with challenges. When he
facilitates parent groups, attendees enjoy having special speakers from advocacy and service organizations come to share
information and experiences.

1. What additional resources, websites, and reading materials might Mike consult to prepare himself for his work in residential
facilities?

2. Which skills might Mike require to effectively facilitate parent groups?

360

Your Career Working With People Who Have Physical, Cognitive, and
Developmental Challenges

Over the next decade, job availability for social workers working in rehabilitative services and with people
who have special needs and physical/cognitive challenges will increase. Often, social workers with a bachelor’s
degree find work in such settings. Social workers are found in all kinds of organizations, from community
nonprofit hospitals and outpatient public or ambulatory care clinics to inpatient for-profit hospitals,
transitional care rehabilitation units, assisted-living and long-term care facilities, and through home health
agency referrals. Social workers who practice with people who have challenges may serve as residential
counselors, consultants, group-home workers, or generalists. They provide information and referrals, serve on
help lines, work in community-based residential facilities, advocate in supportive employment and vocational
rehabilitation programs, and coordinate “day services” to maximize independent functional levels in self-care,
physical and emotional growth, mobility, socialization, community transportation, leisure time and recreation,
and educational and prevocational skills.

To have a successful career in social work with people who have physical/cognitive challenges or special needs,
it is helpful to have the following:

Understanding of the classification systems and diagnostic terminology for various physical, cognitive,
and developmental conditions
Understanding of the roles of all professionals (e.g., vocational rehabilitation specialists) working with
people with physical, developmental and cognitive challenges
Understanding of health disparities and stigma
Understanding of the biopsychosocial-cultural and spiritual aspects of multiple types of challenges
Crisis intervention skills
Short-term counseling skills
Knowledge about culturally competent assessment, counseling, and community resources

These social workers must also work to rid themselves of stereotypes and fear of people with physical,
cognitive, and developmental challenges.

Most people will have a physical/cognitive challenge or special need in their lifetime, and people often live
with such challenges for a long time. That means many people may at one point or another require a social
worker to help them navigate services, resources, and health care. When a person has no family; has trouble
coping with a physical, cognitive, or developmental challenge; or has experienced undue pain, injury, or
suffering; social workers can help.

Summary

Let me win. But if I cannot win, let me be brave in the attempt.

Special Olympics Athlete Oath

361

Because physical, cognitive, and developmental challenges and/or special needs are equated with dependency and still stigmatized,
they are positioned in direct contrast to American ideals of independence and autonomy. Social work must advocate for people not
to be labeled as inferior citizens and for systems to be made equally accessible to all. Dependency is not bad—it is at the heart of
both the human and the American experience. It is what makes a community and a democracy.

Over time, America has gone from relative homogeneity to increased levels of categorization for people who experience challenges of
any sort. It is important to remember, though, that challenges or special needs are not the story of someone else; they are the story of
someone we love and perhaps even the story of who we are or may become. That being the case, it is important to see the common
humanity in all who have been diagnosed with a physical, cognitive, or developmental challenge.

362

Top 10 Key Concepts

Affordable Care Act (ACA) / American Health Care Act (AHCA)*
Americans with Disabilities Act (ADA)
categorical versus functional disabilities
deinstitutionalization
genetic counseling
independent-living centers
public accommodations
rehabilitative services
social stigma
special needs

* For a statement from the National Association of Social Workers on these two acts at time of publication,
see http://www.socialworkblog.org/advocacy/2017/05/statement-nasw-strongly-opposes-legislation-to-
repeal-affordable-care-act/

363

Discussion Questions
1. What does it mean to live with a physical, cognitive, or developmental challenge?
2. How do social work values and the Code of Ethics guide social workers who practice with people who live with physical, cognitive,

or developmental challenges?
3. How do Americans still stigmatize people living with physical, cognitive, and developmental challenges? Consider all the types of

challenges and name some specific actions, attitudes, and expressions.
4. What resources would you seek if you or a loved one had a special need?
5. What roles do social workers assume if they work with people who have a physical, cognitive, or developmental challenge?

364

Exercises
1. The opening vignette features Joe, an administrator who works with The Arc. Explore the history of The Arc and write a

reflection on the importance of grassroots organizations for people with intellectual disabilities/challenges.
2. Locate family members or friends who have special needs (physical, cognitive, or developmental challenges). Ask them what

concerns they have about their lives. Write a report on how one of these persons has managed his or her life (e.g., issues at school
and in the workplace, and activities of daily living).

3. What famous people (dead or alive) had or have a particular physical, cognitive, or developmental challenge, yet still made valuable
contributions to society? Start by investigating some of the following:

a. Artists and musicians: James Durbin (autism advocate, guitarist, and singer who finished fourth in Season 10 of “American
Idol”); Ludwig van Beethoven (composer with a hearing disorder); Ray Charles (African American musician and singer
who was blind); Francisco Goya (Spanish painter who became deaf at age 46)

b. Actors: Henry Winkler (played “The Fonz” on the TV show Happy Days and has dyslexia); Marlee Matlin (Oscar winner
who is deaf and uses sign language); Michael J. Fox (lives with Parkinson’s disease)

c. Historical figures: Julius Caesar (Roman Emperor who had epilepsy); General George Patton (WWII hero who had
dyslexia); U.S. President George Washington (had a learning challenge that affected his spelling); U.S. President Franklin
D. Roosevelt (polio affected his mobility); Albert Einstein (physicist and mathematician who had a learning challenge)

4. How can students become more aware of and engaged with people who live with physical, mobility, neurocognitive,
developmental, or mental challenges?

5. How does your campus serve people who live with learning, developmental, or physical challenges?

Online Resources

The Arc (www.thearc.org): Advocates for the rights and full participation in society of all children and adults with
intellectual and developmental challenges, such as autism, Down syndrome, fetal alcohol spectrum disorder, and a range of
intellectual and developmental conditions
Disability is Natural (www.disabilityisnatural.com): Website for a user-friendly book, wherein parents learn revolutionary
common sense techniques for raising successful children with disabilities
The International Network of Women with Disabilities (inwwd.wordpress.com): Comprises international, regional,
national, and local organizations, groups, and networks of women with special needs; seeks to enable women with challenges
to share knowledge and experience, enhance the capacity to speak up for rights, encourage empowerment, and promote
relevant policies toward creating a more just and fair world that acknowledges disability and gender, justice, and human
rights
National Association of Social Workers’ Help Starts Here (www.helpstartshere.org/health-and-wellness/disabilities/how-do-
social-workers-help-the-families-of-children-with-disabilities.html): Offers abundant resources for social workers who
choose to specialize in services to people with special needs
National Center for Learning Disabilities (www.ncld.org): Offers a plethora of resources for people struggling with learning
challenges , in school or work
National Society of Genetic Counselors (nsgc.org): Involved in federal advocacy efforts aimed at improving access to quality
genetic counseling services and ensuring that the genetic counseling profession is a recognized and integral part of the health
care system
Special Olympics (www.specialolympics.org): An international program, founded in 1968, that promotes fitness and athletic
competition for children and adults who are living with intellectual or physical challenges
UN Enable (www.un.org/disabilities): Works to promote the full and effective participation and inclusion in society of
people with special needs

Student Study Site

365

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

366

Chapter 9: Mental Health

Source: iStock Photo / SilviaJansen

367

Learning Objectives
After reading this chapter, you will be able to

1. Explain the differences between mental health and mental illness, and between normal and abnormal mental health.
2. Identify at least five types of serious mental health disorders.
3. Explain the medicalization of mental health and its effect on individuals as well as on mental health professionals and

organizations.
4. Describe in broad terms how mental health has historically been defined and treated.
5. Understand the importance of mental health parity and its current status.
6. Identify mental health social work roles and settings.
7. Recognize how diversity affects mental health and mental health treatment.

Joyce Seeks Knowledge to Help With Her Broad Caseload at a Mental Health Center

Joyce’s caseload at Henrico Mental Health fluctuates in size, yet steadily includes a wide range of ages and presenting issues. The
agency has a respected, long-standing positive reputation in the community, and clinicians there use an array of intervention
techniques and treatment modalities. Joyce is a MSW-prepared social worker who has held the licensed clinical social worker
(LCSW) credential for ten years. As an independent practitioner, Joyce is skilled in cognitive behavioral therapy, dialectical behavior
therapy, solution-focused approaches, and motivational interviewing. She keeps documentation notes on all her clients that are clear,
substantive, evidence-based, goal focused, and measureable. Joyce also makes sure her continuing education credits are up-to-date—
especially the credits she is required to have in ethics and cultural competency. Her agency accepts multiple types of insurance.
However, when insurance coverage ends, Joyce refers clients to other agencies—such as faith-based organizations or community
support groups—for follow-up.

Joyce regularly attends local National Association of Social Workers chapter meetings and online webinars and workshops to keep
current on mental health parity law, the Diagnostic and Statistical Manual of Mental Disorders classification system, and more. Such
activities provide Joyce with important policy and practice information she requires to help her in her assessments, interventions, and
advocacy efforts. She also makes sure that every two years she fulfills the continuing education requirements for her LCSW
credential. Because of her many years of mental health practice, Joyce is regularly recruited to teach practice courses in the local
university bachelor’s in social work program. In her lectures she makes sure to highlight the uniqueness of social work–prepared
mental health providers, and the realities of social work practice in psychiatric hospitals, private practice, and public versus private
mental health practices.

Social workers are the largest providers of mental health services in the United States (Masiriri, 2008;
National Association of Social Workers, n.d.; Scheyett, 2005; Zellmann, Madden, & Aguiniga, 2014).
Mental health social workers are known as clinical social workers, psychiatric social workers, psychotherapists,
or behavioral health care specialists. These professionals help diverse individuals with mental or emotional
disorders manage social problems and life’s challenges. Emerging areas of mental health social work practice
have been identified in two areas: assisting clients with obtaining supportive, competitive employment, and
working with clients to obtain postsecondary education (Shankar, Martin, & McDonald, 2009).

Mental health social workers assess (evaluate) and work with people who have mental disorders and behavioral
and addiction problems that often occur alongside these disorders. (Substance use and addiction are discussed
in more detail in Chapter 10.) Mental health social workers may specialize in child, adolescent, adult, or even
older adult (geriatric) mental health; forensic social work; counseling for persons with developmental, physical,
or neurocognitive disorders; or drug and alcohol rehabilitation. They regularly collaborate with a team of

368

psychiatrists, psychologists, and nurses.

The purpose of this chapter is to describe the evolution and current state of mental health services in the
United States and help you understand the roles social workers assume in mental health settings. You will find
that ideas about the most effective treatment for people with mental illness have fluctuated over the years. The
most recent policy trend—dehospitalization or deinstitutionalization—has served to increase the need for
outpatient services, which is a key venue for social work with those who have a mental illness.

369

Mental Health and Mental Illness

Failure to cope adequately with the demands of everyday life may be a sign of a mental health problem or
disorder. When a person is suffering, maladaptive (a danger to self), unpredictable to the point of losing
control and being irrational, causing an observer discomfort, and violating a moral or social standard, that
person is failing to function adequately (Rosenhan & Seligman, 1989). Mental disorders are common in the
United States and globally. Although mental disorders are widespread, the main burden of illness is
concentrated in about 6% of the population. One in five people experience a mental health condition and
about 1 in 17 people suffer from a severe mental illness (Hooper, 2017). Mental illness is caused by multiple
factors, including accidents, poor choices, and genetic predisposition.

370

Definitions of Mental Health Status

Many people engage in behavior that is harmful, maladaptive, or threatening to self, but we don’t necessarily
classify them as abnormal. Consider participation in high-adrenaline sports, drinking alcohol, smoking, or
skipping classes. Definitions have helped mental health professionals distinguish between good mental health
and mental illness.

Mental health connotes a relative state of emotional well-being where one is free from incapacitating conflicts
and is consistently able to make rational decisions and cope with environmental stresses and internal pressures.
By contrast, mental illness is a disease that causes mild to severe disturbances in thinking, perception, and
behavior. Mental illnesses are symptoms of mental disorders, which vary in duration and severity, and can
affect persons of any age, class, race, and ethnicity. If these disturbances significantly impair a person’s ability
to cope with life’s ordinary demands and routines, then the person will likely require proper treatment from a
mental health professional.

The terms behavioral health and mental health are often used interchangeably, and the term perceptual health
has also been introduced because helping professionals’ perceptions may often lead to harmful actions toward
patients. Behavioral health includes prevention and well-being promotion and is a hopeful concept for people
who feel that mental illness is a permanent part of their lives. Behavioral health is also a kinder term than
mental health and may help reduce the stigma. The term stigma refers to a sense of disgrace and shame that
can be intentionally or unintentionally bestowed by others. Behavioral health can also place the onus on the
individual to change rather than considering external environmental factors such as poverty, discrimination, or
abuse, thus obliterating the underlying causes of suicidal behaviors and conveying a concept more reminiscent
of an insurance company than of someone struggling with mental health issues (Sandler, 2009).

371

Normal Versus Abnormal Mental Health

Undergraduate social work majors often take courses that debate what kind of behavior is normal versus
abnormal. These courses may be called “Personality” or “Abnormal Psychology,” and they explore ways
abnormality can be defined. The problem is that the multiple definitions of abnormality fail to distinguish
between desirable and undesirable behavior. Statistically speaking, many very gifted people could be classified
as “abnormal” by some definitions.

Also, social norms change over time and thereby complicate definitional matters. For example, homosexuality,
until 1990, was considered a psychological disorder by the World Health Organization’s International
Classification of Diseases, and the American Psychiatric Association did not remove homosexuality from the
Diagnostic and Statistical Manual of Mental Disorders (DSM) until 1973. Today, however, homosexuality is
considered acceptable and not a mental disorder.

Spotlight On Advocacy

372

Tim Howard and the NJCTS Leadership Academy for Youth Living
With Tourette Syndrome
Tourette syndrome (TS) is a neurobiological condition characterized by tics. In the fifth edition of the DSM, it is referred to as
“Tourette disorder” and listed among neurodevelopmental disorders usually first diagnosed in childhood and adolescence. People
erroneously think that people living with TS curse sporadically or have intellectual challenges, because the media make fun of these
people without understanding why they make noises, twitch, or move oddly or incessantly. The reality is that, although TS poses
challenges, they can be overcome through various treatments, adjustments, advocacy, and education. Probably the biggest challenge
for people living with TS is building the self-confidence to fulfill their potential (Benshoff, 2014).

Tim Howard, goalie for the USA World Cup soccer team who set a new world record of 16 saves in the 2014 game against
Belgium, lives with TS. Given his success in sports, few have questioned his abilities. In conjunction with the New Jersey Center for
Tourette Syndrome and Associated Disorders, Howard lent his name to launch a leadership academy, envisioned as an annual event,
to offer youth living with TS the skills they need to manage life’s challenges. The New Jersey Center for Tourette Syndrome
(NJCTS) coordinates this annual event (http://njcts.org/teamup/).

Over 3 days, the leadership academy hosts three teams of teenagers, ages 14 to 17, and coaches, ages 21 to 29, who all have TS.
Psychologists, educators, neurologists, and social workers offer workshops on the mind and coping psychologically and socially with
life despite their TS. Building self-confidence, boosting self-esteem, and focusing on resilience are core goals of the academy. By
engaging in workshops, team meetings, and experiential activities that involve creativity, advocacy, self-leadership, and teamwork,
academy participants leave thinking and acting more like Howard—a person who is a self-leader and advocate for TS. Because the
youth attending the academy know firsthand what it feels like to be bullied, isolated, scapegoated, and misunderstood, they absorb
knowledge about TS, acquire advocacy and social skills, and leave the academy with a sense of empowerment, resilience, and
realization that they can drive, attend a university, play sports on the world stage—and have TS (Fowler, 2014).

There is a video of the 2017 Academy at https://photos.app.goo.gl/jXUZdXyDxbcFR9w93.

Most mental health care providers would agree that ideal mental health includes the following (McLeod,
2014):

Accurate perception of reality
Autonomy and independence
Capability for growth and development
Environmental mastery—ability to meet the varying demands of day-to-day situations
Positive friendships and relationships
Positive view of the self

The reality is that ideal mental health is not always obtainable, and the human brain affects human thoughts
and actions. But because not all symptoms and problems in living are caused by mental disorders, mislabeling
can be very harmful to people who are deemed “abnormal.”

Similarly, when a person has been evaluated as having a mental illness or mental disorder, it is important to be
sensitive about the language used to describe her or him. Person-first language, discussed in detail in Chapter
8 in relation to physical and mental challenges is meant to play up the individual’s worth and downplay the
challenging condition. For example, instead of saying, “He’s bipolar,” it would be more appropriate to refer to
“a man with bipolar disorder.”

373

Time to Think 9.1

What do you think the consequences might be of labeling any person “abnormal”? Similarly, what would be the consequences of
referring to someone by mental illness—for example, as “a schizophrenic”? How might such a label affect a person who is managing
life quite well? How might it affect someone who is struggling in one or more of the areas of mental activity listed as ideal?

Mental illness presents challenges for individuals and their family members.

Source: iStock Photo / monkeybusinessimages

374

Mental Health Disorders and the DSM

In America, mental health disorders are classified and diagnosed based on the DSM. This manual, published
by the American Psychiatric Association, serves as a universal authority for psychiatric diagnosis. Oftentimes,
treatment recommendations and payment by insurance companies to health care providers are determined by
DSM diagnostic codes. Mental health social workers routinely use the DSM to “label patients”—particularly
at inpatient hospitals, mental health clinics, and outpatient health centers—so the client can be reimbursed
through insurance.

The DSM is currently in its fifth edition (DSM-5; American Psychiatric Association, 2013), and every update
has brought noteworthy changes. For example, the current edition dropped Asperger’s syndrome as a mental
disorder and changed the criteria for posttraumatic stress disorder (discussed in more detail below).

In its opening section, the DSM acknowledges that definitions of mental disorders are imprecise. The
definitions actually describe patterns of behavior and severity levels that are evident. Forthrightly, the DSM
states that people are not diagnosed; their disorders are.

Although DSM classification occurs regularly in real-world social work practice, social work educators
continue to debate the utility of teaching such classification schemas. The DSM has both proponents and
critics. Critics find it necessary to remind mental health counselors that their relationship with a client should
come first and that any diagnosis should be a team effort. In addition, a member of DSM task forces who is a
clinician, educator, researcher, and leading authority on psychiatric diagnosis (Frances, 2013) has noted some
specific problems with the DSM-5:

The DSM-5 suffers from the unfortunate combination of unrealistically lofty ambitions and sloppy
methodology. . . . Unless diagnoses are used with restraint millions of essentially normal people will
be mislabeled and subjected to potentially harmful treatment and unnecessary stigma. The DSM-5
has lowered the requirements for diagnosing existing disorders. For example, 2 weeks of normal
grief have been turned into Major Depressive Disorder. The criteria for adult ADHD have been
loosened, making it easily confused with normal distractibility and facilitating the illegal misuses of
prescription stimulants for performance enhancement or recreational purposes. The DSM-5 has
collapsed early Substance Abuse and end-stage Substance Dependence (addiction) into one
category, confusing their very different courses and treatment needs and creating unnecessary
stigma. (p. 5)

Time to Think 9.2

Why do you suppose social workers perceive and use the DSM differently from the way it is perceived and used by psychiatrists,
psychologists, and psychiatric nurses? As a prospective social worker, what are the advantages and disadvantages you see in using this
type of a system to classify and code mental disorders?

375

Despite the controversy, social workers in the mental health field need to be familiar with these types of
disorders and the way they are defined in the DSM-5:

Neurocognitive disorders: The new descriptor for disorders that involve delirium or dementia.
“Dementias” include diseases such as Alzheimer’s, which leads to loss of mental functions, including
memory loss and a decline in intellectual and physical skills.
Personality disorders: The cause of vicious cycles of negative experiences where people cannot adapt to
change and become distressed. Personality is an enduring pattern of behaving, feeling, interacting, and
thinking that forms who we are. Ten personality disorders are classified in the DSM-5: borderline,
antisocial, narcissistic, histrionic, obsessive-compulsive, avoidant, dependent, paranoid, schizoid, and
schizotypal personality disorder.
Anxiety disorders: Formerly lumped together with depressive disorder and bipolar disorder under the
classification of “mood disorders,” anxiety disorders, which include phobias and panic disorders, are
common. People who suffer from phobias experience extreme fear or dread of particular objects or
situations. Panic disorders involve sudden intense feelings of terror for no apparent reason and
symptoms similar to those of a heart attack.
Depressive disorders: Formerly categorized as mood disorders, along with anxiety and bipolar disorders,
depressive disorders are also common. People lose their ability to concentrate, think clearly, or make
simple decisions when they experience depression.
Bipolar disorder: This was formerly listed among mood disorders such as anxiety and depressive
disorders. Diagnoses of bipolar disorder abound. Between 1984 and 2014, diagnoses of childhood
bipolar disorder have increased fortyfold, thereby becoming an epidemic and a “fad diagnosis.” A bipolar
diagnosis carries the connotation that it will last for a lifetime and require continuous treatment with
medication (Frances, 2013, p. 53).
Schizophrenia spectrum and other psychotic disorders: A serious disorder that affects how a person acts,
feels, and thinks, schizophrenia is believed to be caused by chemical imbalances in the brain that
produce multiple symptoms, including delusions, hallucinations, impaired reasoning, incoherent speech,
and withdrawal.
Eating disorders: This label includes anorexia nervosa and bulimia, which are serious, potentially life-
threatening illnesses. People with these disorders have a preoccupation with food and an irrational fear
of being fat. Anorexia is self-starvation, while bulimia involves cycles of binging (consuming huge
amounts of food) and purging (abusing laxatives or self-inducing vomiting). Behavior may also include
excessive exercise.
Neurodevelopmental disorders: This broad category includes three noteworthy disorders, usually first
diagnosed in childhood and adolescence—attention-deficit hyperactivity disorder (ADHD), autism
spectrum disorder, and oppositional defiant disorder. Depending on its presentation, autism may be
deemed a disability or simply a mental health issue. The fundamental truth about developmental
disorders such as autism and dyslexia is that they are wrongly classified as childhood disorders. They are
lifelong conditions that can be exacerbated by stress and unfamiliar situations, and can lead to mental
collapse (Frith, 2014, p. 671). While autism has always been with us, it has been recognized only since

376

the mid-20th century. Despite this slow start, the spectrum of autism is now incredibly broad.
Posttraumatic stress disorder (PTSD): Applies when someone has suffered through an unusually
dreadful trauma (e.g., combat, rape, torture, battery, or qualifying catastrophes such as fires, accidents,
floods, earthquakes, hurricanes). However, the diagnostic criteria are more descriptive of the symptom-
based outcome than of the precipitating event itself. One person may suffer PTSD due to a precipitating
event that others might not consider “unusually dreadful.” There are numerous variables that can
influence whether and to what extent an event or experience is traumatic. Recovery from an accident,
traumatic brain injury, or physical abnormality requires specialized treatment and an interdisciplinary
team approach.

An eating disorder can be extremely dangerous for a person’s health.

Source: iStock Photo / GeorgeRudy

377

Evolution of the Mental Health System

Chapter 8 includes a history of services for people living with cognitive and physical challenges—
developmental, physical, and neurocognitive disabilities. In many ways, the history of perceptions of and
treatment for mental illness tracks closely with that of disabilities; however, services and legislation for people
with mental health disorders have traditionally been separated from those for people with physical challenges.

Time to Think 9.3

Does it make sense for physical, cognitive, and developmental challenges and mental health services to be separate? Why or why not?

Do you think that people with physical and cognitive challenges and people with mental illness experience the same stigma and
discrimination in employment, housing, and other areas? If not, how would you explain the differences?

378

Institutionalization and Deinstitutionalization

The institutionalization of people subject to bizarre outbursts dates back to the 13th century. European
colonists brought their views of how best to care for people who were mentally ill to North America. They
thought institutionalization of people who needed a safe, controlled environment was a good idea. However,
in colonial America there was no institutionalization—if you were experiencing a mental disorder, you were
left to your own devices or jailed as a criminal. It wasn’t until 1773 that “hospitals” specializing in mental
health opened in the United States.

Today, institutionalization is a core part of what many think about when talking about challenging conditions
in the United States. However, in the United States, institutionalization has more often had the connotation
of criminalization than of treatment. People in power often viewed people with mental health conditions as a
threat to social and political structures. Political thinkers supported a movement toward long-term
hospitalization so the “insane” could not access the rights of citizenship and make societal decisions.
Institutionalization can serve larger ideological purposes as well. The warehousing of those considered deviant,
coupled with the threat of sterilization, literally controlled the reproduction of troublesome norms of behavior
(Nielsen, 2012, p. 119). Consider that suicide was not struck from all states’ lists of felonies until the 1990s.

In the 1960s, U.S. policymakers and citizens began to embrace deinstitutionalization. It was in large part the
philosophy behind the civil rights movement and the 1963 Community Mental Health Act that put an end to
long-term hospitalization for people with developmental challenges, people with mental illness, criminal
offenders, and children and older adults (Segal, 1995). The rationale that helped make deinstitutionalization a
reality, however, was preventing unnecessary admissions to institutions and thereby containing costs. As the
United States closed down its large residential institutions, mental health care shifted to outpatient treatment
in clinics, short-term hospitalization, and supervised group homes in the community.

After Medicaid was passed in 1965, community mental health centers tried to accommodate the patients who
were being released from state medical hospitals. This strategy allowed Medicaid to extend coverage for
psychiatric hospital care to people living in poverty and created incentives for states to place in nursing homes
older adults who manifested behavioral problems. As a result, during the 1960s the nursing home population
doubled (Grob, 1991). Some who were released did not completely understand what was transpiring. Staffers
in some of the facilities did not fully understand the mental health needs of their new charges.

Although the philosophy that undergirded deinstitutionalization was “laudable,” it has been the “largest failed
social experiment in twentieth century America” (Torrey, 1995, p. 1612, cited in Peternelj-Taylor, 2008, p.
185). In some jurisdictions, deinstitutionalization has dramatically increased homelessness and been blamed
for the criminalization of people with mental challenges.

379

Medicalization of Mental Illness

Another hotly debated policy of the era was the medicalization of mental illness. Medicalization is a 1970s
term devised by sociologists to explain how medical knowledge is applied to behaviors that are not self-
evidently biological or medical in nature, as a form of social control. One effect of medicalization is a
conceptual shift from labeling disorders as “badness” to regarding people with mental disorders as “sick.”

Medicalization is also referred to as “pathologization” and speaks to the role and power of professionals,
patients, and corporations with ordinary people whose self-identity and life decisions evolve but amidst social
control. In other words, medicalization is a social process whereby human experience is culturally defined as
pathological and treatable as a medical condition. For example, alcoholism, childhood hyperactivity, obesity,
and even sexual abuse have been defined as medical problems that are, as a result, increasingly referred to and
treated by physicians.

Medicalization is a topic that generates mixed opinions and debate among social workers and others. Some of
course see medicalization as taking control of a condition away from the person who has it and instead giving
control to a medical professional. A potential advantage of this shift is the possible reduction of stigma
associated with mental disorders (Payton & Thoits, 2011). In addition, medicalization can afford new
opportunities for access to professional medical care and thus encourage optimism that a therapy can be
developed to treat or cure the disorder.

Time to Think 9.4

Do you think that by treating mental illnesses with medical interventions, individual responsibility, blame, and possibly stigma
related to deviance can be reduced? Or do you think that medicalization of mental illness diffuses responsibility, increases
dependence on medical interventions, and renders social interventions obsolete?

380

Social Work Perspectives

In the mid-1800s, activist social worker Dorothea Dix heightened awareness of the inhumane treatment that
was occurring inside institutions that housed people with mental health challenges, disabilities, and behavior
problems (Caplan, 1969). In the early 20th century, Mary Richmond—the founder of social casework and
author of the classic texts Social Diagnosis (1917) and What Is Social Case Work? (1922)—showed how poverty
was closely linked to mental health, personality development, and effective coping skills in social work clients.

Richmond was a contemporary of Ida Cannon, the social worker employed by Massachusetts General
Hospital to work with clients with mental health problems. In 1913, Mary Jarrett was hired by the Boston
Psychopathic Hospital as its first director of social services. Jarrett is credited for coining the term psychiatric
social worker (Grob, 1991).

Following World War I (1914–1918), social workers in hospitals and clinics helped soldiers with physical and
psychological problems such as “shell shock” and trauma. Subsequently, hospital-based medical/health social
work started to grow.

Freudian theory became popular in the United States during the 1920s, and people who could afford
counseling services sought mental health assistance. Soon child guidance clinics and juvenile court systems
opened to help children with emotional problems and mental health disorders. In 1922 in St. Louis, the first
clinic staffed by a team that included a psychologist, a psychiatrist, and a social worker was opened, and this
model evolved into what is now called a “mental health team.”

During World War II (1939–1945), the Army created officer-level positions for psychiatric social workers,
and they became members of neuropsychiatric teams. As World War II ended, Veterans Administration
hospitals became the largest recruiter of professional social workers, a trend that continues today.

The National Mental Health Act of 1946 represented the first major piece of approved mental health
legislation. This act federally supported demonstration projects, training, and research to examine effective
prevention and treatment programs for mental illness. Subsequently, in 1949, the National Institute of
Mental Health (NIMH) was created. Mental health social work continued to grow. In the 1950s, a social
theorist named Helen Harris Perlman wrote Social Casework: A Problem-Solving Process (1957), and Florence
Hollis wrote the classic social work text Casework: A Psychosocial Therapy (1964). From the 1960s until current
times, social work mental health practice has also been influenced by other policies, court cases, and
movements.

381

Mental Deficits Versus Personal Assets

Prior to the major mental health movements, those who were experiencing mental illness were most often
subjected to moral treatment. In the 1800s, moral treatment advocates, influenced by Enlightenment
thinking, rejected using manacles, chains, and restraints. Instead, these advocates believed that people in
asylums should be treated humanely, like children rather than animals. Yet asylum patients were still thought
to have something wrong with them, deficits that needed to be overcome. As people learned more about the
workings of the mind and body, the mental hygiene movement came into existence. Before it was called the
mental hygiene movement, it strived to reform institutional care, establish child guidance clinics (1921), and
educate the public about mental health. The movement promoted the idea that government was responsible
for mental health and people with deficits, and played a significant role in organizing mental health care for
the military in both world wars. After the world wars, mental health professionals garnered better publicity for
mental health, and in return more funding was allocated to mental health care. After 1947, the mental
hygiene movement supported community mental health centers’ behavioral–scientific and collective approach.
These centers were intended to treat people and change society.

Deinstitutionalization of the mentally ill has caused homelessness in many jurisdictions, and many believe it is
to blame for the criminalization of the mentally ill.

Source: iStock Photo / milenslavov

Mental health care has evolved greatly since the days of the mental hygiene movement. As early as 1880,
when the National Association for the Protection of the Insane and the Prevention of Insanity was formed,
asylum physicians found it hard to defend their practices, which were mainly focused on a deficits approach.
In the context of asylums, a deficits approach meant that more focus was placed on illness and disorders than
on well-being. The goal was to prevent deviation rather than illness. The community mental health
movement began to influence the treatment of mental illness after World War II. When hundreds of World
War II veterans returned with psychological problems, trauma, and battle fatigue, beliefs about mental illness
were questioned, but deficits in the soldiers’ makeup were still the focus. Soldiers diagnosed with a mental
health problem, such as depression, PTSD, or anxiety, felt stigmatized and were perceived as “weak.”
Therefore, many hesitated to accept counseling services or pharmacologic treatment. Even later, in 1946,
when Congress established a Mental Hygiene Division in the U.S. Public Health Service, and in 1949, when
the NIMH research center began, deficits were the focus. Blame and responsibility for mental health
challenges were attributed to the soldier rather than to the traumatic combat environment.

382

The legal advocacy movement and deinstitutionalization movement both continued to diminish the assets of
people with mental illness. Following the civil rights movement, the 1960s marked the start of the legal
advocacy movement in mental health. Essentially, the legal advocacy movement highlighted two landmark
court cases: Wyatt v. Stickney (1971) and O’Connor v. Donaldson (1975). In these cases the Supreme Court
ruled that mental illness and need for treatment were insufficient to justify involuntary confinement, thereby
supporting deinstitutionalization but doing little to increase dignity and personal choice (Mu-Jung & Lin,
1995).

As medications were developed, in the 1960s and 1970s, the deinstitutionalization movement relocated people
from state hospitals back into the community. Unfortunately, the deinstitutionalization movement’s outcome
illustrated how a piecemeal and nonintegrated approach to the social problem of helping the mentally ill
results in spending more on determining eligibility than on providing food and shelter to people who live with
mental illness. Following deinstitutionalization, America’s mental health system was hideously expensive,
wasteful, inefficient, and relatively devoid of dignified treatment and personal choice.

Today, the consumer movement has taken hold. Activists and established groups such as the National
Alliance on Mental Illness (NAMI) are involved in advocacy efforts that dismiss deficits and stigma and
strongly uphold a focus on assets. NAMI was founded in 1979 by people with mental illness who called
themselves “consumers,” along with their family members and concerned professionals. NAMI supports
research, education, social policy, and political activities that help improve access to community-based
services. Today, NAMI has affiliate offices in all 50 states. Mental health teams now collaborate to link clients
with community-based day programs that teach skills to people diagnosed with mental health problems and
urge physicians to prescribe a broad assortment of psychotropic medications, such as antidepressants and
antimanic medications, that help people with mental illness function well in society.

Exhibit 9.1 Mental Health Movements

Source: Content modified from www.careerinfonet.org and www.mymajors.com.

The environment has changed significantly. In the early 1970s, when George McGovern was running for
president, it came out that his vice presidential running mate, Thomas Eagleton, had suffered depression,
been hospitalized for it, and received electroconvulsive therapy. The revelation was so shameful that Eagleton
was dropped from the ticket without discussion, demonstrating the power of stigmatization, and McGovern
lost the election in a landslide. Today, however, thanks to activists such as NAMI members, people with

383

mental illness hold esteemed positions in the workplace and wider society. A few esteemed individuals who
have overcome mental illness are actress Catherine ZetaJones, who lives with bipolar disorder; Olympic
swimmer Michael Phelps, who excels despite his ADHD; mathematician John Nash, who won a Nobel Prize
despite living with schizophrenia; and guitarist Keith Urban, who successfully overcame alcoholism and
continues to write songs and serves as a judge on the American Idol television show.

Exhibit 9.1 provides an overview of the important movements related to mental health care in the United
States.

384

Mental Health Parity and the Affordable Care Act

Private practice or licensed clinical social workers may provide psychotherapy to treat mental disorders; this
was the preferred treatment for mental illness for many decades. However, psychotherapeutic counseling has
declined since the 1990s because of restrictions on the number and type of mental health services covered by
insurance plans.

For decades, activists attempted to improve insurance coverage for the treatment of mental illness. They were
interested in mental health parity with medical health policy. In other words, a person who has been
diagnosed with a mental disorder should receive the same level of professional care as a person diagnosed with
a physical disorder, and mental health professionals should be reimbursed for their services as are physicians
and other medical personnel.

Initial reactions to the Mental Health Parity Act, which took effect in 1998, were positive. Under this act,
employers who provided mental health benefits to their employees could not place stricter caps on those
benefits than they placed on medical and surgical benefits. The National Association of Social Workers
(NASW, 2001b) celebrated passage of the act and called it a “first step” toward mental health parity.
However, it eventually became apparent that this act would not have the desired effect. It did not require
employers to provide mental health benefits, and it did not keep insurance plans from imposing other
restrictions on mental health benefits (Moniz & Gorin, 2014). In 2008, the earlier act was replaced by the
Mental Health Parity and Addiction Equity Act, which fixed the gaps and added insurance coverage for
addiction treatment as well. Up for debate is whether this act truly ensures parity now or still contains flaws.

Since passage of the Affordable Care Act (ACA) of 2010 (aka ObamaCare), Medicaid has become the major
source of funding for mental health treatment in the United States (Barry & Huskamp, 2011; Davis, 2008).
The ACA emphasizes several emerging models for mental health care (Isett, Ellis, Topping, & Morrissey,
2009; McConnell, 2013):

Integrated care: Also referred to as collaborative care, this is care coordination for people with psychiatric
disorders, including general medical illness and substance use disorders.
Medical home: This is the medical care base (usually the primary care doctor) through which all patient
care, for medical and mental health services alike, is tracked. This is a patient-centered rather than
provider-centered approach. Ideally, the patient will have little sense of getting different kinds of
services from different locations. The medical health care providers must always work collaboratively
with the mental health team and the patient’s family.
Accountable care organizations: Groups of physicians, hospitals, and other health care providers who
voluntarily join together to render coordinated high-quality care to their Medicare patients.

Reforms in the mental health care delivery system, embedded in the ACA, are meant to address long-
standing system fragmentation. Typically, primary care doctors and specialty behavioral health care providers,
such as therapists and counselors, have not coordinated their treatments for individual patients. Patients with

385

coexisting mental health and addiction disorders are particularly in need of good coordination among all their
care providers.

On May 3, 2017, under the Trump administration, the House narrowly passed and the Senate narrowly did
not pass the American Health Care Act (AHCA), which would have repealed provisions of the ACA and
massively cut the Medicaid program. Under the proposed AHCA, patients with mental health and addiction
disorders would have likely been hurt, because they disproportionately rely on Medicaid and Medicaid
expansion health plans for health coverage (Pellitt, 2017).

Exhibit 9.2 U.S. Legislation and Court Cases Related to Mental Health

Social Work in Action

386

Asha Grapples With Ethical Issues
Psychiatric social worker Asha is well aware of how boundaries figure in the lives of social workers, especially those working one-on-
one with people with mental illness. She lives in a remote rural area in Alaska, accessible only by plane or boat, and no other
counselors are available in the region. Asha has to purchase her winter fuel supply from a man who is now one of her psychotherapy
clients. John, of Pacific Islander descent, has been in therapeutic counseling with Asha for 2 months because of his divorce,
depression, and co-occurring alcohol addiction.

Usually, the winter fuel purchase in this community is a major negotiating event because there are no other options for buying it.
Asha grapples with how to haggle with her client and get a “fair market price” in light of the dual nature of their relationship. John’s
problems are far from being addressed, although he appears to be committed to treatment and recovery.

1. What would you do if you were Asha?
2. What options does John have, given the geographic context and availability of mental health professionals?

A series of government actions starting in the 1960s, summarized in Exhibit 9.2, has brought us to the current
situation. People with mental health disorders are receiving more and better help than ever. Following the
2012 Newtown, Connecticut, tragedy where a man fatally shot 20 students and 6 staff members at Sandy
Hook Elementary School, NAMI prepared a report that summarized trends, themes, and best practices in
state mental health legislation, and circulated it to mental health advocates around the nation (Carolla, 2014;
National Alliance on Mental Illness, 2013). Because Medicaid is the primary funding source for public mental
health services, states guided by the ACA must now make decisions about expanding Medicaid for mental
health services. NAMI’s report outlines legislative goals for states to consider, such as mental health parity,
civil rights protection and advocacy, integrated mental health/substance use/primary care, supported
employment and housing, early identification and intervention, and more.

387

Social Work Practice in Mental Health

Mental health social workers often work across boundaries. Social workers see many clients who have
combinations of health, mental health, disability, and substance use problems. At the same time, their work
often requires collaboration among professionals in the medical, criminal justice, educational, and social
services systems. A social worker often serves as the case manager—the one person, other than the client, who
knows how everything interconnects.

388

Social Work Roles in Mental Health Services

Exhibit 9.3 outlines multiple tasks that are often the responsibility of either BSW- or MSW-prepared mental
health workers. As you can see, the possibilities are expansive. Purposeful and empowered consultation
relationships can also help to promote clinical effectiveness, client welfare, counselor wellness, and ethical
practices (Carney & Jefferson, 2014).

One of the most distinctive roles of social workers in the area of mental health is therapy, or clinical social
work. Licensed clinical social workers are directly responsible for assessing, diagnosing, and treating all forms
of mental health disorders, including serious mental illnesses such as major depression, schizophrenia, and
substance-related disorders (Theriot & Lodato, 2012). The job often requires great patience and ingenuity in
breaking through the client’s disordered thinking and helping the client cope well with her or his social
environment. Another reality is that people often “wait until their suffering is so desperate that it finally
outweighs the fear, mistrust, or embarrassment that previously prevented them from seeking help” (Frances,
2013, p. 6). Other challenges confront the mental health social worker. For example, they often help families
cope with trauma, loss, and addiction.

Exhibit 9.3 What Mental Health Social Workers Do

Sources: CareerOneStop (www.careeronestop.org) and MyMajors (www.mymajors.com).

A good example of how complex a clinical social worker’s role may become involves an increase in services for
recovery from a combination of traumatic brain injury (a physical disability) and PTSD (a mental disorder
often resulting from military service). These conditions are complex in and of themselves; together, they
require integrated services from medical and mental health personnel. Sometimes the problem can be handled
quite quickly, but other times it may require ongoing monitoring and care. PTSD can be addressed through
individual or family counseling, or group therapy. Oftentimes, family members of patients with traumatic
brain injury and PTSD require as much if not more counseling than do the patients themselves, because while

389

the patient looks the same as before, she or he now thinks and behaves differently and cannot necessarily
control her or his thoughts and actions.

390

Mental Health Literacy

The term mental health literacy, first used by Australian researcher Anthony Jorm and his colleagues in the
late 1990s as an extension of the term health literacy, refers to being able to recognize disorders and obtain
mental health information (Mendenhall & Frauenholtz, 2013). Literacy facilitates understanding. The
NASW (2018) has identified universal access to health and mental health care as one of social work’s top
priorities and includes health literacy in its initiative. However, largely excluded from the formal list of
priorities is the need for mental health literacy.

Mental health literacy has value across multiple mental health settings. Social work clients and staff who have
not had professional training need to understand the signs, symptoms, and treatments for various disorders.
The most severely affected mental health consumers in community settings may not be able to achieve mental
health literacy themselves and may be limited in their ability to share mental health information with others.
Thus, social workers need to provide individualized psychoeducation for friends and family of people who live
with mental health disorders. Social workers must also advocate for and prioritize mental health literacy as a
goal of U.S. health care policy. Interventions could include public campaigns, agency- or school-based
programs, online interventions, and information sharing through social media.

Therapy animals can facilitate coping.

Source: Scott Olson / Staff / Getty Images

391

Mental Health Settings

Current social workers provide mental health services in multiple settings, including the following:

Community mental health programs: Overseeing assessments, interventions, and evaluations of people and
programs related to mental health services
Disaster relief programs: Planning and implementing international and humanitarian relief and response
efforts for victims of natural and other disasters
Employee assistance programs: Managing conflicts and providing information, referrals, and counseling to
people experiencing problems with their physical or, mental health
Hospitals and skilled nursing facilities: Facilitating intakes, discharge planning, and monitoring of ongoing
acute and chronic care needs. Social workers also practice in what have traditionally been called
“psychiatric hospitals,” where mental health intervention is the primary reason for hospitalization.
Military and veterans services: Providing direct service, supervision, administration, research, and policy
formulation related to the Department of Defense
Rehabilitation programs: Supporting clients to recover and rehabilitate from mental health and co-
occurring disorders
Schools: Helping teachers and educational professionals evaluate students’ behavior at school to provide
early intervention; sharing information with students, teachers, and administrators about mental health
and mental illness; and guiding schools toward funding to expand mental health services
Private practice: MSW-prepared practitioners with a LCSW or LISW (Licensed Independent Social
Worker) credential (depending upon state requirements) may engage in independent practice and bill
for third-party reimbursement from insurance companies. Individuals, or two people or more may own a
private practice where they counsel clients and/or run therapeutic groups (Carney & Jefferson, 2014).
Social workers often enter private practice groups with other professionals (e.g., psychologists,
counselors, and psychiatrists). Although private practice may seem lucrative and a highly desirable mode
of practice, private practitioners essentially run businesses and accordingly need to be attentive to
marketing, collection of fees, accounting, rental of space, and establishing means for supervision
Employee assistance programs: Counseling employees with personal problems and workplace issues
Inpatient and outpatient clinics: Helping clients adapt to significant lifestyle changes related to a loved
one’s death, disability, divorce, or job loss; providing substance use treatment; and helping people who
experience anxiety, depression, a crisis, or trauma
Interprofessional practice settings: Implementation of mental health services can also occur in the context
of interprofessional practice settings. For example, Long and Rosen (2017) describe the provision of
mental health services by social workers at an eye center in a college of optometry.

392

Digital Mental Health Information and Therapy

Young and old alike can experience mental health issues. When it comes to learning about mental illness and
therapy or treatment, however, adults respond best to brochures and self-help books, television or radio
messages, paid advertisements, and face-to-face counseling. In contrast, the younger generation craves
connection and information through social media and digital devices.

To provide effective mental health treatment to youth, 21st century health care providers must cross the
“digital divide” and offer online and mobile options to support youth who wish to successfully manage their
mental health problems. Young people respond to websites, Twitter, blogs, online questionnaires, and chat
rooms. Therefore, providing mental health information via the Internet and social media platforms such as
Facebook can enhance the self-help capacity of young people. Smartphone applications that can help improve
some mental health habits also exist.

Computer-mediated activities such as e-counseling and e-therapy can also be used in treatment for people
who are comfortable with digital technology and the Internet. Some treatment approaches can be applied even
better in virtual environments, such as exposure-based therapies, which are efficacious for many phobia and
PTSD issues. Other options involve using avatars or Comic Chat. Comic Chat, now called Microsoft Chat
2.5, allows players to take on the role of a character in a comic strip.

Current Trends

393

Peer Support
Peer support–based interventions are increasingly being deployed. One estimate suggests that groups, organizations, and programs
run by and for people with serious mental illness and their families outnumber professionally run mental health organizations by a
ratio of almost 2 to 1 (Lucksted, McNulty, Brayboy, & Forbes, 2009). Three forms of peer support include consumer-run services,
naturally occurring mutual support groups, and the employment of consumers as providers within clinical or rehabilitative settings
(Davidson et al., 1999).

Peer-based interventions have been developed based on the idea that people who experience mental illness can help others who
experience similar mental health conditions. Although evidence exists to support the efficacy of structured self-management
programs for chronic physical conditions such as diabetes and asthma, limited research has evaluated this approach for mental
disorders (Cook et al., 2009).

A review of peer specialist roles and activities demonstrated common activities, which include these: address self-determination and
personal responsibility; support health and wellness; address hopelessness; address stigma in the community; develop friendships and
other social support; provide education, transportation, illness management, leisure, and recreation; and assist with communication
with health care providers. At a lesser level these roles support the development of psychiatric advance directives, and supports for
dating, parenting, spirituality and religion, citizenship, employment, and family relationships (Salzer, Schwenk, & Brusilovskiy,
2010).

1. How can social workers encourage the creation and functioning of peer supports?
2. How can peer supports be evaluated to assure they are encouraging self-determination and personal responsibility, and are

being supportive and health oriented?

Source: Daniels (2010).

Many people find support and information through peer support sites, where people who share similar
diagnoses can compare notes. However, it is important for mental health professionals, including social
workers, to become comfortable with online media as well so their knowledge and experience can help inform
people with mental health concerns (Rickwood, 2012, p. 25).

Whether counseling or resource information sharing occurs in person or through social media and the
Internet, mental health social workers must remember that the client comes first and must be served with
respect, worth, and dignity.

394

Diversity and Mental Health

In and of itself, a mentally healthy population is paramount for enhancing unity, social integration, and
inclusiveness in our society. Another consideration, however, is how the diversity of the American population
plays out in the prevalence and treatment of serious mental illness. Exhibit 9.4 depicts the varying rates of
mental illness among subgroups based on sex, age, and race or ethnicity. The paragraphs that follow elaborate
on those differences.

Age. Mental health problems can occur at any age; however, recognition of mental health problems in
children and adolescents is a relatively recent phenomenon that began in the late 19th century. That is
not to say that mental illness does not exist in this age group: A large U.S. study found that “half of all
mental disorders emerge by 14 and three quarters by 25 years of age. Translated this means that by the
age of 21, 51% of young people will have experienced a diagnosable psychiatric disorder” (Rickwood,
2012, p. 18).
Class. The relationship among health disparities, mental health disparities, and socioeconomic status is a
complex and important one. The connection between the mind and the body is undeniable: Afflictions
of the mind affect physiology, and afflictions of the body in turn affect psychology. The
disproportionate rates of mental health problems in the lower social class show that mental health is
associated with social inequality (Aneshensel, 2009). Additionally, the effects of negative social
interactions and stigma are inversely associated with health and well-being (Chou & Chronister, 2011).
Working-class people are more likely to be diagnosed with a mental illness than are those who are not
from manual-labor backgrounds.
Race and ethnicity. Although Exhibit 9.4 shows that African Americans have a lower rate of serious
mental illness than the overall average for Americans, African Americans are more likely than their
white counterparts to be diagnosed with schizophrenia (Bresnahan, Begg, Brown, Schaefer, & Sohler,
2007). On the other hand, non-Hispanic blacks are 40% less likely than non-Hispanic whites to
experience depression during their lifetime. Exhibit 9.4 also shows that American Indians and Alaska
Natives have a prevalence of mental illness far above that experienced by any other group shown in the
chart. Historical traumas in the form of forced relocations, cultural assimilation, multiple broken
treaties, and other social and economic injustices have contributed to health and mental health
disparities in this population. Mental health and disabilities also exert a disproportionately negative
effect on racial and ethnic minority children. One reason for the disparity was cited in the final report of
the President’s New Freedom Commission on Mental Health (2003): “Specifically, the system has
neglected to incorporate respect or understanding of the histories, traditions, beliefs, languages, and
value systems of culturally diverse groups” (p. 49). Because some social work disability specialists and
mental health service providers lack cultural competence, people of color frequently do not seek services
in the formal system. Also, they are more likely to drop out of care, be misdiagnosed, or seek care only
when their illness is at an advanced stage. “Fifteen percent of African Americans, 13 percent of
Hispanics, and 11 percent of Asian Americans said there had been a time when they felt they would
have received better care if they had been of a different race or ethnicity” (National Alliance on Mental

395

Illness, 2012, p. viii).
Gender. In the United States, major depressive disorder is one of the most common mental disorders.
Women are 70% more likely than men to experience depression during their lifetime. Comparatively, in
the United Kingdom, depression is also more commonly identified in women. Premenstrual disorders
affect up to 12% of women, and the subspecialties of psychiatry and gynecology have developed
overlapping but distinct diagnoses that qualify as a premenstrual disorder. The burden of disease can be
high, as women with PMS or PMDD (premenstrual syndrome or premenstrual dysphoric disorder)
have higher rates of work absences, higher medical expenses, and lower health-related quality of life
(Hofmeister & Bodden, 2016).

Exhibit 9.4 Prevalence of Serious Mental Illness Among U.S. Adults

Source: National Institute of Mental Health (2013).

Sexual orientation. Lesbian, gay, and bisexual young people are at increased risk of mental health
problems, particularly on measures of suicidal behavior and multiple disorders (Remafedi, French, Story,
Reshnick, & Blum, 1998; Ryan & Futterman, 1998). Until recently, some gay men have also been
pressured to “treat” their sexuality through mental health interventions. Most experts today agree that
homosexuality cannot be “cured”—and in fact, should not even be considered a mental illness. The
NASW (2000) position statement on this subject points out that research findings showing that
conversion therapies work are confounded, and the organization does not stand by such therapies as a
means of changing sexual orientation. Indeed, the NASW has stated that conversion therapies may
actually harm mental health.

Spotlight On Advocacy

396

397

Social Workers Try to Eradicate Stigma
The social work profession is recognized as one of the primary providers of mental health services by esteemed entities such as the
National Institute on Mental Health and the Council on Social Work Education. People with mental illness are one of the
vulnerable and oppressed populations that social workers serve. Integral to effective practice is helping students acquire knowledge,
skill, and a theory base so they can grow into effective practitioners as they work with people who have mental health concerns.
Helping to identify personal attitudes and stereotypes about mental illness and understanding stigma is critical. The literature on
mental illness and stigma, treatment, and client-worker relationships incorporates a broad range of impairment levels (Zellmann,
Madden, & Aguiniga, 2014).

In focus groups, mental health consumers have reported how treatment providers seem to unknowingly hold negative biases toward
them. Although stigma can manifest in multiple forms, the most prominent form discussed in empirical literature, in relation to
mental health, refers to social stigma. Dudley (2000) has defined stigma as stereotypes or negative attitudes attributed to a person or
group of people when they have characteristics or behaviors that deviate from or are perceived as inferior to social norms of the
community.

Three paradigms have emerged to explain mental health stigma: motivational biases, social cognitive theories, and sociocultural
perspectives. When such paradigms have been used in studies, findings reveal that students report positive attitudes toward working
in mental health and seeking treatment; and those who think mental health work is rewarding are less likely to fear or be
uncomfortable around people with mental health issues (Zellmann, Madden, & Aguiniga, 2014). To ensure that social workers in all
practice areas are able to effectively provide needed services, social work education needs to include opportunities for increasing self-
awareness of negative attitudes about mental illness and for countering those attitudes.

398

Advocacy on Behalf of People With Mental Health Issues

Social workers in the mental health sector engage in advocacy, and the demand for them is high. When
people have a mental illness or addiction, they require support, information, and referral amid complex
systems and insurances. Social workers counsel, run groups, educate to eradicate stigma, and advocate for
policy changes. Mental health disorders or mental illness needs to be treated like cancer, diabetes, and heart
disease, where prevention, education, and open communication occur in ways every citizen can understand.
Mental health social workers have the compassion, listening, interpersonal, organizational, problem-solving,
and time-management skills to help clients get their needs met.

399

Economic and Social Justice

People who have comprehensive insurance coverage can afford private practice mental health counseling.
Those without adequate coverage must resort to public or government-funded organizations. Those in the
middle often receive mental health services through managed-care organizations, which can limit the client’s
access to care and the ability for health providers to get paid. Mental health social work advocates need to
keep up with ACA (and the new iterations of the AHCA), as well as mental health policy changes, in order to
subsequently counsel people about the best way to receive the best type of counseling services. Social workers
also need to be attentive to and rebuff federal and state health care legislation that could reduce mental health
coverage and counseling services.

Many Americans are watching the Trump administration to see how they will deal with a central tension
surrounding mental health. There exists debate as to which model for mental health care is best. Some believe
the medical model of psychiatry, which emphasizes drug and hospital treatment, is best; others promote a
psychosocial model, which puts more emphasis on community care and support from family and peers.
According to Dr. Allen Frances, a professor emeritus of psychiatry at Duke University, “The federal agencies
most responsible for the welfare of people with severe mental illness and substance problems have all failed
them miserably” (Cary & Fink, 2017).

For clients who present with co-occurring disorders—for instance, depression and substance use, or paranoia
and aggressive tendencies—social work treatment is shifting to a holistic approach that involves combining
rather than separating health care, substance use treatment, and mental health care. Increasingly, social
workers in mental health will be required to have the skills and knowledge to provide treatment for co-
occurring mental health disorders simultaneously.

400

Supportive Environment

The physical place where people live affects health and mental health alike. For example, living on the street,
under a bridge or boardwalk, in a rescue mission or Salvation Army shelter, near a railroad or shipyard, or in a
home plagued with asbestos or an abandoned meth lab may expose people to environmental toxins and
triggers. Lead exposure affects brain development, and children who get lead poisoning may be at risk for
learning problems and serious illness. Prenatal influences and maternal stress have also been associated with
mental illness.

Additionally, one’s place of residence influences potential access to mental health services. City dwellers may
be close to teaching hospitals, clinics, and other treatment facilities. Residents in rural areas may have
extremely limited access to such services. In response, social work advocates can recognize how rural people
are a diverse and at-risk group based on their often high rates of poverty, fewer life prospects, and stigmatized
social status (Riebschleger, 2007).

No matter the quality of their environment, individuals who are being treated for mental health issues can face
stigma simply as a result of being social work clients. The stigma increases for those who are subjected to
enforced intervention. People who are treated through residential care also typically face a loss of autonomy,
intrusive surveillance, or, in the worst cases, the possibility of abuse. Communities of mental health care are
designed to improve community acceptance of people with chronic mental illness.

401

Human Needs and Rights

People need and deserve respect and acceptance, regardless of their mental health. People with a mental
disorder still require understanding, and people with substance use problems need to know that they have a
disease and not a character defect. At the very least, social work professionals should support their feelings of
self-worth by using person-first language.

Users of mental health services face risks from medication and other forms of treatment, and from services
that fail to engage them effectively (Stalker, 2003, p. 225). Social workers can help clients living with mental
illness better understand what types of medication they are taking, why they are taking them, and what side
effects may occur. Also, some medications must be taken at particular times and with particular dietary
restrictions, and doctors and nurses may not always fully explain these details to patients.

Another area of mental health services that requires advocacy related to human rights is the racial and ethnic
disparity in treatment providers. Ten years ago a U.S. Surgeon General report recommended developing a
more racially diverse workforce to provide mental health services for racial and ethnic minorities (Lowry,
2014). Still today, however, more mental health social workers representing varied races and ethnicities are
needed to meet the needs and numbers of consumers.

402

Political Access

The mental health field of practice demands that social workers be involved in cause advocacy, such as these
policy issues:

Why so many nonspecialized providers are delivering mental health services and discussing psychotropic
medications with clients
Why both rural and urban areas experience a lack of available emergency care and residential treatment
services
What needs to be done about cost containment and continuity of care issues
How to increase the number of inpatient hospital beds to reduce the poor outcomes of shifting so many
clients who are seriously mentally ill to outpatient care

These issues will not be easy to resolve. Presidents and congressional leaders have claimed to want to stop
ineffective policies and support funding for more inpatient beds and more community mental health centers;
however, actual progress in the political arena has been slow.

Social workers and other mental health professionals have also been dismayed by the political factors, both
blatant and hidden, that affect mental health disparities and mental health literacy. For example, cultural
differences, medical mistrust, provider biases, stereotyping, and poor or misleading communication about
mental health services can yield varying mental health outcomes. Most definitions of psychological
abnormality have been devised by white, middle-class men, which has led to disproportionate numbers of
people from certain races and ethnic groups being diagnosed as “abnormal” (Corcoran & Walsh, 2012).

Social Work in Action

403

John Beard Implements the Clubhouse Model
One example of an effective psychiatric rehabilitation model that focuses on providing people who are mentally ill with a supportive
environment is the clubhouse model. Just about anywhere rehabilitation practitioners gather, they talk about this model. The term is
often cited in professional literature and at conferences and seminars. Nearly synonymous with the clubhouse model is the Fountain
House in New York City, which every year serves about 1,300 people who have severe mental disorders (Fountain House, 2014a). It
has been praised widely and is the first of several other Fountain Houses worldwide. The man most responsible for this success is
social worker John Beard.

An article in the Psychosocial Rehabilitation Journal describes the clubhouse model (Beard, Propst, & Malamud, 1982). The goal is to
help severely disabled psychiatric patients improve their social skills through life in a community based on mutual support. The four
core beliefs of the clubhouse model are productivity, work, social interchange, and autonomy. Each person in Fountain House is
assigned to a work unit that is essential to operation of the facility, such as clerical, culinary, or maintenance work. A variety of living
options are available, including shared onsite apartments offering support services and offsite apartments. The ancillary components
of Fountain House include a transitional employment program, an evening and weekend program, a thrift shop, and outreach
programs. Every person in the community is expected to support every other community member. As one of the residents put it:
“They helped me make it on my own, yet I was never alone” (Fountain House, 2014b).

Beard was executive director of New York’s Fountain House for 28 years. Through his work, the clubhouse model was established
and concepts that are seminal to the field of psychiatric rehabilitation were developed. Yearly, the John Beard Award is presented to
someone who makes an outstanding contribution to the field of psychiatric rehabilitation.

1. What kind of knowledge and skills might mental health social workers require to work with the chronically mentally ill
population in a setting that uses the clubhouse model?

2. How do the four core beliefs of the clubhouse model encourage personal empowerment for people living with mental health
challenges?

404

Your Career in Mental Health Social Work

As much as 35% of social workers list mental health as their primary practice (Whitaker & Arrington, 2008).
As illustrated in Exhibit 9.5, the demand for social workers specializing in mental health is expected to
increase, and future job opportunities are quite good. Government economists predict that job growth for
mental health social workers will be much faster than the average for all careers through 2020. With the
ACA, mental health parity resulted in many more people being eligible for mental health coverage under their
insurance plans. Such policy changes contribute to this increasing need for mental health social work
professionals.

Social workers are uniquely educated and trained as mental health providers. Clinical social workers have
advanced expertise in mental health assessment and intervention with individuals, because they embrace the
person-in-environment perspective and strengths perspective. As a result, there is professional recognition of
environmental factors and an accompanying commitment to contribute to larger scale mezzo- and macro-level
change for addressing client needs.

Mental health social work is also an attractive career because clinical social work tends to pay well. However,
money is not normally the main factor that leads someone to become a mental health social worker. In fact,
social workers throughout the mental health system have been willing to accept less pay than nurses, which
has resulted in more social workers being hired (Beinecke & Huxley, 2009).

Time to Think 9.5

What might be attractive about working as a clinical, psychiatric, or other mental health social worker, in a mental health setting or
in private practice?

Exhibit 9.5 Expected Job Growth in Some Subfields of Mental Health

405

Source: Bureau of Labor Statistics, 2010.

BSW social workers often serve as behavioral assistants and/or are case managers in mental health settings.
They must be familiar with mental illnesses, be compassionate communicators, and know community
resources and viable treatment strategies. By contrast, MSW-prepared social workers may be expected to
provide psychotherapeutic counseling and complete diagnostic coding. In all states, social workers in clinical
practice are required to be licensed, registered, or certified. Both BSW- and MSW-prepared social workers
are required to know how to conduct thorough assessments, develop practical treatment plans, and evaluate
progress. Both may serve as advocates for policy change and as activists to advance movements for the cause of
people who are mentally ill. Burnout in the mental health social work field is a reality; so social workers must
learn and use strategies to combat it (Acker, 2011). Meanwhile, advances in neuroscience, technology, and
pharmaceuticals offer the potential for new treatments, prevention strategies, and policies.

Current Trends

406

The Brain Initiative
The Brain Initiative was conceived and funded by the federal government in 2014, with the goal of revolutionizing our
understanding of the human brain. Researchers have craved this type of funding for a long time so they can seek new ways to cure,
treat, and maybe even prevent brain disorders.

If we figured out how our brains work, maybe we could cure mental illnesses or create very smart robots. Scientists want to build a
computer model of the brain, and the Department of Defense has invested about $40 billion in this project. The Brain Initiative
differs from the Human Genome Project in that it plans to study individual neurons, focus on brain imaging, and do computer
simulations of neuronal networks. Essentially, the initiative will coordinate research on how the brain functions over an organism’s
life span. (For more information about this development that is funding neuroengineers and others, go to
www.nih.gov/science/brain.)

1. How much more informative might brain images be than human behavior studies in teaching us about the human brain?
2. Why might social workers have a vested interest in the Brain Initiative?

Summary

Out of suffering have emerged the strongest souls; the most massive characters are seared with scars.

Kahlil Gibran

The mental health field grants multiple sources of identity, interest, status, and career opportunities for social workers at the BSW
and MSW levels. Historically, a large number of social workers secured employment in private and public psychiatric hospitals,
community mental health centers, general public or for-profit hospitals with psychiatric units, outpatient clinics and inpatient units
in university settings, as well as private practice (Davis, 2008). Across these settings mental health social workers collaborated with
multidisciplinary teams to offer therapy and other practical support, such as help with homelessness and unemployment, to people
with mental health problems. Mental health social workers are involved in planning, policy, and administration of agencies.

Because treatment of mental disorders occurs frequently in general medicine, social workers may not be the first mental health
professionals to identify a client’s mental disorder or substance use treatment needs. As a result, some mental health patients are
simply receiving medication from their physicians, without the counseling and other services that could help them overcome their
symptoms as well as their problems with living. But times are changing in the field of mental health services, and with new policies
favoring mental health parity, more people may receive effective treatment. Time will also tell how mental health services will evolve
in the era of burgeoning technology, demographic changes, and a holistic, integrative focus among mental health practitioners.

407

Top 10 Key Concepts

deinstitutionalization
Diagnostic and Statistical Manual of Mental Disorders (DSM)
medicalization
mental disorders
mental health parity
mental illness
posttraumatic stress disorder (PTSD)
psychopharmacology
psychotropic medications
stigma

408

Discussion Questions
1. Why do some social work professionals question the use of the DSM-5 classification system to understand mild, moderate, or

severe mental disorders? What are the advantages and disadvantages of the DSM?
2. Would you be okay with a mental health facility’s opening near your home? What stereotypes do you have regarding mental illness

and those who are severely mentally ill?
3. What is your view on psychopharmacology (medication as treatment)?
4. What role does social support play in helping people cope with diseases or mental health conditions?
5. How do people, across cultures, use mental health care facilities and manage risk in their everyday lives?
6. How can the health beliefs and voices of people using mental health services be better understood and advocated for?

409

Exercises
1. Locate research articles or resources that examine how social workers are working to understand mental disorders, and write a

report on your findings. These are some possible topics: What are social work researchers saying about the basis of mental illness?
How can biomedical, behavioral, and social scientists work together to improve early detection, prevention, and treatment of
mental disorders?

2. Choose a mental health disorder to report on. Then use Internet and library resources to gather articles and information about
how this disorder is diagnosed and treated. Include both psychopharmacological and counseling interventions.

3. Research the types of mental health services available in your community. What types of settings and services are most common?
Which seem to be in short supply? Draw a simple map that shows where those facilities are located. What are your conclusions
about your community’s ability to treat all sorts of mental illnesses and disorders and all sorts of people who need mental health
services?

4. Working in groups, research cultural diversity issues in mental health treatment. How do race and ethnicity affect access to
treatment and its efficacy? What aspects of the treatment are insensitive to the needs of culturally diverse people? Explore the full
array of available interventions for people with mental health problems:

Behavioral approaches
Psychopharmacology
Community outreach
Family therapy interventions
Group counseling
Program development
Self-help groups
Therapeutic communities
Rehabilitation and support services

5. Collect research on autism spectrum disorder and discuss your thoughts about whether teens with ASD should be allowed to
drive. Consider how autoimmune disease has been linked to ADHD and how a brief screening for adult ADHD has been recently
developed.

Online Resources

American Association of Suicidology (www.suicidology.org): Seeks to understand and prevent suicide
“An Early History: African American Mental Health” (academic.udayton.edu/health/01status/mental01.htm)
“Hammurabi’s Managed Health Care—Circa 1700 B.C.”
(www.managedcaremag.com/archives/9705/9705.hammurabi.html)
“History of Social Work Research in Mental Health” (www.socialworkpolicy.org/research/history-of-social-work-research-
in-mental-health.html)
National Alliance on Mental Illness (www.nami.org): The nation’s voice on mental illness and advocacy for people with
mental disorders
National Association for Rural Mental Health (narmh.org): Founded in 1977, develops and enhances rural mental health
and substance use services, and supports mental health providers in rural areas
National Institute of Mental Health (www.nimh.nih.gov): Seeks to transform the understanding and treatment of mental
illnesses through basic and clinical research, paving the way for prevention, recovery, and cure
PBS health care crisis timeline (www.pbs.org/healthcarecrisis/history.htm)
SAMHSA Center for Mental Health Services (beta.samhsa.gov/about-us/who-we-are/offices-centers/cmhs): Leads federal
efforts to promote the prevention and treatment of mental disorders; created by Congress to bring new hope to adults who
have serious mental illness and to children with emotional disorders

Student Study Site

410

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

411

Chapter 10 Substance Use and Addiction

Source: iStock Photo / izusek

412

Learning Objectives
After reading this chapter, you will be able to

1. Explain why substance use and addiction occur and why they are so hard to overcome.
2. Understand the role of codependency in substance use and addiction.
3. Explain why prevention of substance use and addiction is so important.
4. Understand social workers’ roles in substance use and addiction.
5. Identify substance use and addiction treatment concepts and settings.
6. Explain why some forms of treatment present moral, personal, and social dilemmas.
7. Recognize how stigma and bias impede the drug abuse recovery process.

Clayton Uses His Addiction Experience in Community Outreach

Before becoming abstinent from drugs and becoming a street outreach worker, Clayton’s past experience with substance use and
addiction took him to crack houses and shooting galleries where he lost himself in the moment. He acquired hepatitis from sharing
dirty needles and feared getting AIDS. Getting a hit, getting high was all that was important, until he landed in jail.

Several years later, Clayton got into a recovery rehab program and earned a BSW degree in social work. Now, Clayton possesses not
only book learning but real-life experience in the world of mental health and substance use. Clayton attends 12-step meetings and
knows the slang terms for drugs, and he’s tuned into the excuses one can make when addicted to drugs. He strives to be committed
to his work and relationships, and counsels clients with warmth, empathy, and natural genuineness. Clients connect with Clayton—
his genuineness and directness convey honesty, and they find it easy to trust him.

No longer is Clayton a hungry, angry, lonely, and tired person; instead, he works as an effective substance use counselor, sits on
community consortiums and boards, and maintains a devoted relationship with his wife.

Sadly, one of Clayton’s sons—a tall, handsome young man named Quincy—has followed in his dad’s footsteps, seeking to escape
from childhood pain through drug use. Quincy made some bad choices and is in jail. Clayton maintains hopefulness for his son as he
himself takes one day at a time. Clayton stays connected with his son, but he does not enable him.

Substance use problems are ubiquitous in the United States and globally. The substances could be alcohol,
tobacco, opioids, recreational drugs, prescription medications, or illicit drugs. Some use of these substances
may not be a problem, such as limited use of alcohol; however, when a person goes overboard and uses
substances to the point that relationships and the ability to cope with ordinary tasks and activities are affected,
that person may be said to have a substance use problem. This definition of substance use and its related
problems has opened helping professionals’ eyes to other addictive behaviors that have little to do with
substances, such as gambling and sex addictions.

The implication is that addiction is more than a behavioral disorder. Aspects of addiction include people’s
behaviors, thoughts, emotions, and interactions with others, including their relationships with family and
community members, and their own psychological state. Science shows that drug addiction is a chronic,
relapsing disease that results from prolonged effects of drugs on the brain. The majority of the biomedical
community considers addiction to be a brain disease expressed in the form of compulsive behavior. Once
addicted, a person moves into a different state of being. Unfortunately, few people with substance use issues
can stop their compulsive behavior on their own.

Professionals who work in substance use may be case managers, clinicians, clinical social workers, counselors,

413

nurses, community support workers, mental health therapists, psychotherapists, or probation agents. Social

workers who specialize in substance use or addiction may be employed at addiction treatment or chemical
dependency centers, community-based treatment programs, hospital-based treatment inpatient programs,
education and prevention organizations, or private rehab centers, many times established by people who have
suffered from addiction themselves.

Process addictions (PA), which include gambling, Internet addiction, sex addiction, exercise addiction, and
eating addictions, have become an increasing area of concern for the addictions field. Yet little evidence exists
that research on PA is actually being translated to counselors and social work practitioners who try to help
people with behavioral addictions (Wilson & Johnson, 2013). PA is defined as any compulsive-like behavior
that interferes with normal living and causes significant negative consequences in a person’s work, family, and
social life (Sussman, Lisha, & Griffiths, 2011).

Some people believe that substance use—in this context the consumption of harmful, potentially addictive
substances—should not be a matter for social concern. In reality, the use of some substances causes
considerable health and social problems for users. The number one cause of preventable illness and death in
the United States is substance use, which extends the idea of substance use to include maladaptive patterns of
use despite adverse consequences. Each year, more than 500,000 deaths—or 1 in 4—in the United States are
attributed to use of alcohol, tobacco, or other drugs (Schroeder, 2010). Those deaths include drug overdoses,
teen suicides, traffic fatalities, murders, and manslaughter. As illustrated in Exhibit 10.1, substance use is also
associated with rapes, assaults, burglaries, thefts, and child abuse. And the health care costs of substance use
are immense when one considers cancer and cardiopulmonary disease from tobacco use, falls and oversedation
from misuse of prescription drugs, or bacterial and viral infections (including HIV infection) from injecting
illicit drugs.

Exhibit 10.1 Health Issues Related to Drug Use and Alcoholism

414

415

Substance Use as a Mental Disorder

Substance use is also linked to mental illness. The fifth edition of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5) defines substance use disorder as a mental disorder associated with the
consumption of a harmful addictive substance. It is a general classification with a broad range of severity, from
mild to severe (American Psychiatric Association, 2013, p. 484). Multiple definitions and criteria exist for the
consumption of specific substances such as alcohol and tobacco.

Addiction comes in many forms including gambling on lottery tickets.

Source: Barcroft Media / Contributor / Getty Images

Social Work in Action

416

Jessica Intervenes to Help Mason Recover
Mason, age 19, is a short, stocky young man with a ruddy complexion and shoulder-length hair. He is receiving counseling from
Jessica, a clinical social worker at the college counseling center, for his depression and chronic episodes of binge drinking. He cannot
seem to resist those beer pong events at frat parties and does not even think about the bacteria and viruses he might be picking up
from this activity.

Mason does not adhere very well to the depression medication he has been prescribed. Sometimes he doesn’t even remember when
he last took it.

At his most recent appointment with Jessica, Mason confided that his father had a long-standing drinking problem. As a child,
Mason would also sometimes observe his father abusing his mother.

While in college and until he is 26, Mason is covered under his parent’s workplace insurance policy. If after graduation Mason
continues to experience depression and alcohol problems, he may be required to sign up for his own health insurance.

1. What information does Jessica need to share with Mason to prevent his mental health and substance use behavior from
worsening?

2. To what extent might codependency issues be relevant to this client’s situation?

The DSM-5 notes that the word addiction is not applied as a diagnostic term in this classification, even
though it is commonly used in many countries to describe severe problems related to compulsive and habitual
use of substances. The more neutral term substance use disorder is preferred in the United States. Gone is the
diagnosis of substance dependence that caused so much confusion in previous editions of the DSM.
Substance dependence refers to continued use or craving associated with greater tolerance to a substance,
leading to ever-higher doses, and the risk of illness when a person stops using that substance (withdrawal
symptoms). Previously, too many people linked the term dependence with addiction, when in fact dependence
can be a normal body response to a substance. However, some social workers in this field still use the word
addiction to describe more extreme cases.

The DSM-5 still includes the term addictive disorders, but it is a new category based on behavioral, not
substance, addictions. Gambling disorder is the only addictive disorder in the DSM-5 that is considered a
diagnosable condition. This new term reflects recent research that links gambling to substance-related
conditions with respect to its brain origin, association with other challenges, physiology, and treatment.

417

Causes of Substance use

Similar to many psychological challenges, substance use depends on two main factors: genes and environment.
Genetic factors account for about half of the likelihood that a person will develop an addiction. An addicting
drug causes physical and biochemical changes to several areas of the brain, changes that exacerbate and are
exacerbated by continuing use of the drug. In essence, addiction is a brain condition with self-perpetuating
tendencies. Although neurobiological researchers do not yet know exactly how genes influence a person’s
tendency to experience changes in the brain and become addicted, they have found definitive signs that
addictive tendencies run in families.

Environmental factors interact with a person’s biology and affect the extent to which genetic factors exert their
influence. The way a person is raised and later life experiences can affect the extent to which genetic
predispositions lead to the behavioral and other manifestations of addiction. Culture also contributes to how
addiction becomes actualized in people with biological vulnerabilities. Moreover, although addiction seems to
be a matter of biology, the decision to start using a drug is influenced by your family’s beliefs and attitudes and
by exposure to a peer group that encourages drug use. People of any age, sex, or class can become addicted to a
substance. However, addiction occurs faster or more readily for those who have a family history of addiction,
have a neglectful family, are male, experience peer pressure to use a drug, experience anxiety and depression,
or begin using a highly addictive drug such as heroin or cocaine.

Time to Think 10.1

What features of American life do you think make American adolescents, adults, and older adults susceptible to addiction to alcohol
and other drugs and harmful behaviors?

418

Codependency

Substance use may also progress because other people in the user’s environment are enabling the substance
use. The term for the relationship between the user and these other people is codependency. They rely on
each other to meet reciprocal needs, especially unhealthy emotional needs. For example, a young woman puts
up with controlling behavior and insults from her boyfriend because she wants to be with a man. Or a dad
steps in to protect his son from the consequences of poor behavior instead of teaching his son the proper way
to behave.

The person with a substance use problem needs treatment to break the grip of the substance or behavior. In
addition, the people who have covered up or enabled the substance use (often referred to simply as
codependents) need counseling to understand how their behavior is hurting everyone. Although they may
accept that their “caretaking” behavior is making it more difficult for the person with the substance use
problem to recover, they often have more difficulty understanding how codependency is hurting them in
return. An example of this caretaking behavior is when a wife covers up for her husband with alcohol
addiction so he does not lose his job.

Researchers and clinicians have found that many people with codependency behaviors focus too much outside
of themselves, do not express their feelings, and take too much personal meaning from their relationship with
the person who has an addiction (Beattie, 2009, 2011; Knudson & Terrell, 2012, p. 245). Codependency
appears to originate primarily in the family of origin, particularly in families where the parents are perceived to
have a turbulent relationship; interestingly, however, codependent behavior does not seem to be related to
substance use in the family of origin (Knudson & Terrell, 2012). In any event, codependents may appear as
people pleasers, denying themselves and their own needs because they are or have been so busy taking care of
others.

419

Addictive Substances and Behaviors

Many types of substances can be used. Exhibit 10.2 is a chart from the National Institute on Drug Abuse that
explains their effects and the dangers of abuse. Here we provide some additional information about the ways
these substances (and a couple of behaviors) affect both those who use them and those who may suffer the
consequences of others’ abuse.

Alcohol

Alcohol is the most commonly used psychoactive, or brain-affecting, substance. About 1 in 4 people who
drink heavily may have alcohol use problems (Larson, Wooten, Adams, & Merrick, 2012; Roman, 2014).
Alcoholism is a chronic and often progressive disease that includes problems controlling your drinking,
physical dependence on alcohol, or having withdrawal symptoms when you stop drinking.

Although it is not always associated with alcoholism, binge drinking is a common problem among young
people. It means drinking so much within about 2 hours that blood alcohol concentration (BAC) levels reach
0.08%. For women this usually occurs after four drinks and for men after five. However, a number of factors,
including the size of the drink and alcohol concentration make simply counting the number of drinks
consumed a poor measure of impact on one’s BAC. Drinking too much, whether as a person with alcohol
addiction or a frequent binge drinker, can affect your brain, heart, liver, pancreas, cancer potential, and
immune system.

Impaired driving related to alcohol, or drunk driving, is a significant public health problem. Generally, in the
United States, a BAC of 0.08% is considered the legal limit for being charged with the criminal offense of
driving while intoxicated (DWI).

The U.S. Department of Transportation found that in 2012, 10,322 people were killed in alcohol-impaired–
driving crashes. Further, these fatalities accounted for 31% of the total motor vehicle traffic fatalities in the
United States (Centers for Disease Control and Prevention, 2011a). According to the Centers for Disease
Control and Prevention, young drivers (ages 16–20) are 17 times more likely to die in a crash when they have
a BAC of 0.08% than when they have not been drinking. Also, 1 in 5 teen drivers involved in fatal crashes in
2010 had some alcohol in their system. Most of these drivers (81%) had BACs higher than the legal limit
(Centers for Disease Control and Prevention, 2011a, 2012b). Based upon these types of findings, especially in
relationship to car wrecks, it is easy to see why alcohol and substance use both constitute significant personal
and public health problems in the United States.

Prescription Drugs

In 2010, about 16 million Americans reported having used a prescription drug for nonmedical reasons in the
past year (Wang, Fiellin, & Becker, 2014). Because older adults tend to be given more prescriptions, they
represent a population with an increased incidence of prescription drug use and concomitant physical, mental,
and social consequences. U.S. teenagers are increasingly using prescription drugs, and misusing prescription

420

drugs, such as narcotic pain killers, tranquilizers, and sedatives, which can lead to addiction (National Institute
on Drug Abuse, 2014). Exhibit 10.3 is a chart from the National Institute on Drug Abuse describing the
effects of depressants, opioids and morphine derivatives, stimulants, and other substances that are meant for
medical use but are frequently used in ways that are not intended or by people to whom they were not
prescribed.

Exhibit 10.2 Commonly Abused Drugs

421

* Schedule I and II drugs have a high potential for abuse. They require greater storage security and have a
quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and
have no approved medical use; Schedule II drugs are available only by prescription (unrefillable) and
require a form for ordering. Schedule III and IV drugs are available by prescription, may have 5 refills in
6 months, and may be ordered orally. Some Schedule V drugs are available over the counter.

** Some of the health risks are directly related to the route of drug administration. For example, injection
drug use can increase the risk of infection through needle contamination with staphylococci, HIV,
hepatitis, and other organisms.

*** Associated with sexual assaults.

Source: National Institute on Drug Abuse (2011a).

Illegal Drugs and Marijuana

Many psychoactive drugs have benign uses as medication or agents in brain research; however, they are
frequently misused. The most commonly abused illegal drugs include cannabis (marijuana), organic solvents
(e.g., toluene, which is used in dry cleaning and the aviation and chemical industries), amphetamines, and
opioids such as morphine. “Designer drugs” are variants created by chemists specifically to avoid falling afoul
of antidrug laws.

Many of these substances have been used for centuries; however, the recreational use of these drugs has been
illegal since the federal law known as the Marijuana Tax Act was passed in 1937. Few may realize that
newspaper mogul William Randolph Hearst used his newspaper to demonize marijuana and print stories that
linked marijuana with violent crime (Deitch, 2003). The new reality is that Americans increasingly see
marijuana as a harmless substance. Illicit cannabis use and cannabis use disorders have increased more in states
that passed medical marijuana laws than in those that did not (Brooks, 2017).

More recent stories report how these drugs can cause addiction and problematic behavior, as well as
permanently impairing the brain and damaging other organs. For example, the effects of marijuana use
include cognitive dysfunction, poor executive functions, and sedative effects. Heart problems and strokes have
also been reported (Malick, 2014).

On a societal level, the global trade in these drugs has disrupted the lives of users and low-level functionaries
working for dealers, often involving them in violence, the criminal justice system, and medical emergencies.
The illegality of the drugs pushes the trade into the shadows and raises the stakes for people involved in the
business. Weapons trading, money laundering, and cross-border disputes among drug cartels also threaten the
security of numerous nations. And the problem is increasing. In the 2009 to 2012 reporting period, the U.S.
Department of Homeland Security (2013) seized 39% more drugs, 71% more currency, and 189% more
weapons along the southwest border than it had in the 2005 to 2008 period.

422

Anabolic Steroids

Anabolic steroids are similar to testosterone and have important medical uses. However, they are also used by
an unknown number of people, especially men, who want to “bulk up” for sports or look more imposing
physically. Steroid users spend huge sums of money and a lot of time obtaining the drugs, which indicates a
possible addiction. Another sign of addiction is a tendency for abusers to keep using steroids despite physical
ailments such as feminization of the body (e.g., shrinking testicles and developing breasts) and negative
repercussions in social relationships due to increased irritability and aggression. Withdrawal symptoms that
steroid users may experience include depression, mood swings, fatigue, restlessness, loss of appetite, insomnia,
reduced sex drive, and steroid cravings.

Tobacco and Nicotine

Tobacco is a relative latecomer to the list of addictive substances. The politics of the tobacco industry led to
tobacco’s classification as merely a “habit or habituation” in 1984 (Mars & Ling, 2008). However, the Philip
Morris Tobacco Company publicly changed its position in 1997, and since then, nicotine, the psychoactive
ingredient in tobacco, has been considered addictive. Multiple court cases also played a role in changing the
classification of tobacco.

As an addictive substance, nicotine might be pleasurable during smoking, but the feeling does not last.
Afterward, smokers feel anxious, moody, and depressed. In addition, nicotine can harm a person’s heart,
lungs, skin, and muscles, and can lead to gum disease. Nicotine addiction is linked to serious health problems
such as bronchitis, emphysema, heart disease, and various forms of cancer.

Nicotine addiction is difficult to overcome, in large part because of the social cues surrounding its use.
Smokers come to value the ritual of lighting up and holding a cigarette. However, research shows that
bupropion (aka Wellbutrin) is more effective than nicotine replacement gums or patches in reducing relapse in
smokers, especially when co-occurring depression is present (Sinacola & Peters-Strickland, 2012, p. 99). The
newer drug varenicline (Chantix) has added value as sustained-release bupropion blocks nicotine uptake in the
brain.

Food and Caffeine

Recent research on the brain’s mechanisms is revealing the psychoactive qualities of some common substances
formerly considered benign. In fact, food is necessary for life; however, it can also be addictive in a way that
shares a similar neurobiological and behavioral framework with substance addiction. Some people derive
psychological pleasure from food.

The greatest potential harm from food addiction is obesity. However, researchers cannot agree on whether or
to what degree food addiction contributes to obesity in the general population. A lone study on food addiction
conducted by a research team in Newfoundland (Pedram et al., 2013) concluded that food addiction
contributes to the severity of obesity. The finding is important, as obesity and overweight are the fifth-leading

423

cause of global death and the second most preventable cause of death in the United States.

Caffeine is not necessary to life, but it has long been incorporated into beverages that are consumed with
pleasure—coffee, tea, carbonated sodas, and sports beverages. As with tobacco, there are social cues that
popularize caffeine, and it is often consumed to improve performance. It is included here because it has some
dangerous physiological and psychoactive effects. Data from college campuses reveals that students’ caffeine
consumption around exam time is excessive, causing anxiety and concomitant sleep deprivation (Hershner &
Chervin, 2014).

Exhibit 10.3 Commonly Abused Prescription Drugs

* Schedule I and II drugs have a high potential for misuse.They require greater storage security and have
a quota on manufacturing, among other restrictions. Schedule I drugs are available for research only and
have no approved medical use. Schedule II drugs are available only by prescription and require a new
prescription for each refill. Schedule III and IV drugs are available by prescription, may have 5 refills in 6
months, and may be ordered orally. Most Schedule V drugs are available over the counter.

** Taking drugs by injection can increase the risk of infection through needle contamination with
staphylococci, HIV, hepatitis, and other organisms. Injection is a more common practice for opioids, but
risks apply to any medication taken by injection.

424

Source: National Institute on Drug Abuse (2011b).

According to the Mayo Clinic, there is no clear link between caffeine intake and depression. But caffeine can
cause sleep problems that affect mood, and abruptly quitting caffeinated beverages can cause depression until
your body adjusts (Hall-Flavin, 2011; Smith, 2002).

Gambling

As mentioned earlier, the DSM-5 reclassified pathological gambling with substance use disorders under the
heading of “Addiction and Related Disorders.” Occasional, casual gambling may not be a problem, but
compulsive gambling—the uncontrollable urge to keep gambling—can thoroughly disrupt a person’s life
(Mayo Clinic Staff, 2014). A person with a gambling addiction often keeps at it until all financial resources
have been lost, which in turn destroys families and other relationships and increases the risk of the gambler’s
turning to crime as a way of either paying off debts or finding more money with which to gamble.

Compulsive gambling typically starts in the teen years and progresses over time. Causes are not fully
understood, however a combination of biological, genetic, and environmental factors is implicated (Loecher &
Harrar, 2001). Researchers have found that gambling addiction and substance misuse are motivated by similar
mechanisms in the brain (Thomas, Allen, Phillips, & Karantzas, 2011). In addition, as with substance misuse,
gambling can be controlled in part through social support.

Sex Addiction

People who grapple with sexual addiction behaviors are not just people who crave lots of sex. Underlying
problems, including stress, anxiety, depression, and shame and guilt, drive their often risky sexual behavior.

Classifying certain types of sexual behavior as an addiction is controversial, and there are limited studies on
the topic. Again, some of the brain mechanisms and psychological effects of so-called sex addiction mirror
those of gambling and substance use. The biggest impediment to accepting compulsive sex as an addiction
seems to be professional caution and misdiagnosis (P. Hall, 2011). Although the DSM-5 does not include sex
addiction, some clinicians are alert to the problem that “hypersexual disorder” may pose to some people,
especially because this behavior tends to put the individual at risk of contracting HIV/AIDS or other sexually
transmitted infections.

Current Trends

425

Public Health Concerns: Chronic Pain and Opioid Abuse
The prevalence of opioid misuse and dependence has increased. Increased availability of opioids permits diversion of prescription
opioids to recreational users. An estimated 75 million Americans who suffer from chronic pain may use prescribed opioids because
pain impairs their daily activities. Pseudo-addiction can be seen in people who are opioid dependent and exhibit drug-seeking
behaviors when their pain management needs are not met (Liberto & Fornili, 2013). Despite the prevalence of substance misuse and
dependence, according to SAMHSA, only 2.3 million users received treatment as hospital inpatients, in an emergency department,
at a drug or alcohol rehabilitation center or mental health facility, or through self-help groups within the past year (Liberto &
Fornili, 2013, p. 34).

Traditional ways to treat opioid dependence include psychosocial and psychopharmacological methods. Methadone is the most
common opioid replacement therapy. It reduces illicit opioid use, increases treatment retention, and can be prescribed for
detoxification or maintenance therapy. Another promising pharmacologic therapy is buprenorphine, a long-acting partial opioid
agonist. Buprenorphine alone (Subtex) and buprenorphine in combination with naloxone (Suboxone) to prevent parenteral abuse are
sublingual formulations approved for outpatient treatment of opioid dependence. The opioid antagonist naltrexone (ReVia) prevents
relapse through a long-acting opioid receptor blockade. These medications allow people to regain some quality of life while their
opioid dependence is managed (incidentally, naltrexone can also be very helpful for overcoming alcohol addiction).

People struggling with opioid dependence, whether illicit drug users or people with chronic pain, have multiple complicated needs,
including high levels of morbidity and mortality, domestic and family problems, homelessness, abuse, victimization, and
unemployment. Often, these concomitant problems result in people being labeled as difficult, challenging, or morally suspect. This
labeling can affect help seeking, care delivery, and treatment. Typical barriers to care include stigmatization from health care
providers, self-stigmatization, discrimination, frequent need for services, anxiety and fear about withdrawal, and lack of professional
skill in identifying and addressing substance use.

People who are opioid dependent can be considered stigma-vulnerable because, while a particular individual might not be
stigmatized, historically the group has been. Public stigma begets self-stigma, and self-stigma results in decreased care seeking.
Social workers trained in managing substance dependence can be assigned to patients with known substance use upon medical
admission. Such a case management approach may be cost effective.

In 2003, the SAMHSA initiated a screening, brief intervention, and referral-to-treatment (SBIRT) program to promote screening
and early intervention for people with alcohol and substance use issues in hospital settings. More about SBIRT is found in a
Spotlight on Advocacy box found on p. 196.

Spotlight On Advocacy

426

SBIRT Training Helps Social Workers
Sbirt grantees perform brief interventions that include motivational interviewing aimed at changing behavior, brief treatment
(multiple enhanced brief interventions), and referral of people identified as substance-dependent to specialty providers. The purpose
of substance screening is to identify people who may have substance use difficulties and to discern whether they require only brief
interventions that can be administered in general health settings, or need referral to specialty addictions treatment providers (Liberto
& Fornili, 2013).

Although social workers regularly encounter clients with substance use problems, social work education rarely addresses addictions
with any depth (Osborne & Benner, 2012). SBIRT training and the use of pre and post questionnaires can assess social workers’
attitudes, knowledge, and skills concerning substance misuse. Substance misuse in the United States is high, with 30% of adults
engaging in at-risk drinking (Osborne & Benner, 2102). Screening, brief intervention, and referral to treatment is based on the
transtheoretical model of change, and incorporates motivational interviewing to “briefly intervene” with clients who are at-risk
drinkers. The transtheoretical model presents 5 stages of client readiness to change: precontemplation (change is not considered);
contemplation (some awareness of consequences but ambivalence to change); preparation (change is planned); action (change
begins); and maintenance (change is managed). The idea is to meet clients where they are among these stages. Then, amidst using
motivational interviewing, the idea is to “roll with resistance” and let clients take the lead in their efforts. SBIRT can be integrated
into the medical home, and delivered by health professionals, including social work advocates. (Osborne & Benner, 2012, p. e38).

Another aspect of sex addiction that has received attention recently is Internet sex addiction, from passive
consumption to online pornography to the interactive exchange of sexual content in cybersex chat rooms. At
this point, the data on the pathological use of Internet sex is inconclusive (Griffiths, 2012). Some therapists,
however, have found that this sort of behavior can stress existing intimate relationships.

427

Policies Related to Substance Use

Legal drugs such as alcohol, tobacco, and prescription medications are loosely regulated and viewed as normal,
and their users are not thought to have a disease. Eight states and the District of Columbia now permit adults
to use recreational marijuana, and 30 states have allowed medical use of some kind. This means 205 million
Americans live in a state where marijuana use is legal in some way, although cannabis remains entirely illegal
at the federal level. By contrast, statutes and laws define illegal or “controlled” drugs and prohibit their use,
possession, manufacture, and distribution. Legislative bodies have also passed laws associated with drug
paraphernalia, money laundering, the sale of drugs to minors and on school property, and organized crime.

Over time, social policies related to substance use have influenced the development of practices and treatment
programs. For example, in colonial America and in the early 1800s, drinking alcohol was accepted, and
opiates and cocaine were legal and widely used. In the 19th century, however, it became problematic to use
alcohol and get drunk. Exhibit 10.4 illustrates a bit of policy history related to alcohol and drug problems in
the United States.

Although social work education did not focus much historically on substance use and disorders, social workers
currently contribute greatly to the field of addictions. Because social workers are the largest group of U.S.
mental health professionals, they must know how to assess, screen, intervene, use motivational interviewing,
and make referrals to help people experiencing substance issues and disorders. Social workers in addiction
services must advocate for more innovative approaches and more inclusion of family members in treatment. At
the policy level, social work advocacy is needed to ensure that state and federal policies are just and effective in
addressing substance issues. Social workers should realize that the field of addiction and substance use is
constantly changing. Concepts and practice interventions that require understanding by substance use and
addiction social workers include abstinence, recovery, stages of readiness for change, motivational
interviewing, cognitive behavioral therapy, relapse prevention training, and harm reduction therapy, to name a
few.

Exhibit 10.4 Historical Evolution of Policies Related to Substance Use

428

Source: Straussner and Isralowitz (2008); Department of Health and Human Services (HHS). SAMHSA
and ONDCP: 2006 Drug Free Communities Support Program (2006).

Current Trends

429

Colorado’s Experiment With Legalized Marijuana
On New Year’s Day 2014, the state of Colorado began allowing licensed vendors to sell marijuana to anyone over the age of 21.
Vendors expected marijuana sales to generate $30 million in revenues and taxes after 1 year. On that measure alone, the recreational
marijuana industry seems to be improving Colorado’s economy. In addition, the legal marijuana economy is expected to prompt new
construction, new jobs, and new investments. Already, new categories of businesses have sprung up around legal marijuana
(Yakowicz, 2014).

Although marijuana is legal according to Colorado law, it is still illegal according to federal law. This means that clients whose
physicians recommend they use medical marijuana may be exempt from criminal prosecution in states that have passed medical
marijuana laws; however, “federal laws make no such exception from the current drug prohibition policy” (FindLaw, 2014).

Not all Coloradans are happy with the new law. Although the law mandates that marijuana must be tracked until it is sold, some
people are concerned about the effect legalization will have on children. In Denver, citizens and the city council expressed concern
that they would soon see 12- and 13-year-olds selling marijuana on playgrounds or an increase in substance use problems.

The effect of changing laws and the legalization of marijuana for medical or recreational use are many and continue to be identified
and studied.

1. What are the pros and cons of legalizing marijuana?
2. What is the advocacy role(s) of a social worker regarding passing laws on the use of marijuana?
3. Should the federal government take a standing on legalizing marijuana? Please explain the reasoning for your response.

Time to Think 10.2

Do you believe substance use is a medical issue (physical illness), a moral issue, a law enforcement issue, or something else? Please
consider how you arrived at this belief.

What policies do you think are needed to reduce substance use disorder and addiction in our country?

430

Social Work Practice in Substance Use and Addiction

A substance use social worker might become involved in case management, crisis intervention, education,
client advocacy, and group therapy. To carry out these tasks, social workers need to interview people, monitor
progress, review records, conduct assessments, assess adherence to treatment plans, and consult other
professionals. They must understand human behavior, personality, interests and hobbies, research methods,
individual differences in ability, and learning and motivation. Also helpful is knowledge of relevant factors
related to group dynamics, societal influences and trends, philosophical systems, religions, and ethnicity. It is
also useful to know about relevant laws and court procedures. Substance use social workers very often need to
read current literature, undertake research, and attend classes, seminars, and workshops. Quite possibly, drug
testing will also be required. Above all, a substance use social worker must be emotionally mature, objective,
sensitive to other people, independent, and responsible.

Often, at least a bachelor’s degree, preferably in social work, is required for work in substance use and
addictions. BSW social workers often serve as behavioral assistants and generalist counselors in substance use
and addiction treatment settings. Securing an entry-level position is sometimes possible with a degree in
sociology or psychology. Many positions require an advanced degree such as a master’s in social work.

Time to Think 10.3

Does clinical social work in a substance use treatment setting seem like a career that might interest you? Why or why not?

Substance use social workers with MSW degrees often focus on counseling. Their clients tend to have issues
that revolve around mental or physical illness, physical abuse, poverty, or unemployment. Social workers
uncover hidden issues and intervene with solution-focused strategies. So along with all the other skills and
knowledge required of social workers in this field, clinical social workers must understand the principles and
methods of diagnosis and treatment of mental illness, and rehabilitation of those who have become addicted.
Many states offer advanced certification and/or licensure options for social workers and counselors practicing
in the area of chemical addiction.

431

Prevention of Substance Use Disorder

The best way to treat substance use disorders is prevention. Once a substance begins to affect the brain, the
desire to use the substance increases and becomes difficult for the individual to control.

Many methods have been tried to prevent substance use. Schools and other community facilities may offer
programs on understanding the ill effects of substance use and fighting peer pressure to use drugs, or require
drug testing in certain circumstances. Some workplaces, especially those whose employees operate public
transit and heavy machinery, also require periodic drug testing. Some require drug testing as a part of the
hiring process. If companies do not drug-test employees, their business could be at risk for negligence lawsuits
from employees and customers alike.

Many smaller businesses do not require drug testing, however. The National Drug-Free Workplace Alliance
reports that small businesses employ the greatest number of substance misusers, because drug users tend to
find work where there are fewer resources to perform drug tests (Konovsky & Cropanzano, 1991). The 2010
National Survey on Drug Use and Health found that 1 in 6 adults working full time in the restaurant industry
had used illicit drugs (Substance Abuse and Mental Health Services Administration, 2011a). The
phenomenon of substance use among restaurant industry employees has been attributed to a labor pool that
averages in age from 16 to 25 years old, late hours, large availability of cash on hand, and low management
surveillance (Kitterlin & Moreo, 2012).

432

Treatments and Interventions for Substance Use and Addiction

Substance use and addiction services have been tailored to help diverse groups of people: people with co-
occurring problems; people from different social classes and of different ethnicities and sexualities; people who
belong to religious groups; athletes and intellectuals; people with physical and mental challenges; urban,
suburban, and rural people; women and men; young people; unemployed people and people with jobs; old
people; and so on.

Treatments and interventions have also been developed to deal with people having trouble with different sorts
of addiction, from use of alcohol, opiates, and amphetamines to behavioral challenges. Moreover, their levels
of addiction vary, although all tend to have gotten to the point where they are experiencing some type of
problem with relationships or responsibilities.

No matter the specifics of the individual case, the substance use social worker should be concerned with
assessing the following issues:

Loss of control (inability to stop or limit drug use)
Tolerance (the need to use more and more of the substance to avoid withdrawal or maintain a desired
state)
Impairment in functioning (e.g., failure to work or keep other life obligations)

Substance use comes with many costs.

Source: Pixabay.com / LauritaM

Social workers may find employment in all the varied treatment settings outlined in Exhibit 10.5.

Detoxification and Recovery

The first step in overcoming either physiological or psychological addiction is detoxification. This short-term,
medically supervised treatment program for alcohol or drug addiction is designed to purge the body of
intoxicating or addictive substances. Detoxing alone and at home is dangerous. If a person stops using
substances too suddenly, she or he can experience hallucinations or convulsions, or have a heart seizure that
can turn deadly. Initial symptoms of detoxification include anxiety, nausea, insomnia, delirium tremens,
shakiness, and seizures. People suffering multiple substance misuse issues need professional medical help to
detox safely. Detoxification is only the beginning stage of addressing addiction.

Exhibit 10.5 Treatment Settings for People With Substance Use and Addiction Challenges

433

Source: Inspired by Smyth (1995).

Recovery follows detoxification and is the lifelong process of learning to live without the substance of misuse.
The Substance Abuse and Mental Health Services Administration (SAMHSA), a federal entity that
promotes prevention of and treatment for substance use, announced a new working definition of recovery in
2011: “A process of change through which individuals improve their health and wellness, live a self-directed
life, and strive to reach their full potential” (SAMHSA, 2011b).

SAMHSA has also delineated four major dimensions of life that support recovery:

Health: Overcoming or managing one’s disease(s), as well as living in a physically and emotionally
healthy way
Home: Maintaining a stable and safe place to live
Purpose: Pursuing meaningful daily activities, such as a job, school, volunteerism, family caretaking, or
creative endeavors, and the independence, income, and resources to participate in society
Community: Forging relationships and social networks that provide support, friendship, love, and hope

SAMHSA has also developed some guiding principles for people in recovery, which are reproduced in Exhibit
10.6.

Typically, a person in recovery is assisted by some kind of treatment center. The vast majority of treatment
centers have a zero tolerance model that requires total abstinence from the substance that has led the client
into treatment (Sinacola & Peters-Strickland, 2012). Beyond that, treatment centers may follow any of a
number of models for promoting recovery (Sinacola & Peters-Strickland, 2012). Here are a few of the most
common:

12-step approach: Traditional treatment model based on a moral and spiritual understanding of addictive
behavior.
Rational-recovery model: Teaches people with substance use disorder to recognize and dispute irrational
thoughts that encourage substance use. Addictive thoughts are referred to as the BEAST—Boozing
opportunity, Enemy voice recognition, Accuse the voice of malice, Self-control and self-worth

434

reminders, Treasure your sobriety (Trimpey, 1994).
Harm reduction model: A motivational approach to increase people’s desire for better health and well-
being. The model encompasses abstinence/harm elimination, recovery readiness, moderation
management, substitution therapy, relapse prevention, and environmental prevention. The model is
similar to moderation management and is often used with individuals who misuse multiple substances,
because it views substance use behaviors on a continuum.

Exhibit 10.6 SAMHSA’s Guiding Principles of Recovery

Source: Substance Abuse and Mental Health Services Administration (SAMHSA), 2011b.

Social Work in Action

435

Judy Uses Motivational Interviewing to Assess Bob
Dr. Judy Sames completed her social work dissertation on using groups in school settings. During her doctoral program, Judy
noticed how particular mental health and substance use social work professionals tended to use motivational interviewing (MI) in
groups and in counseling individuals. She bought books that described how and when to use MI, and recently attended a continuing
education workshop on using MI with veterans. In her private practice, Judy is working with Army veteran Bob. Bob is 70 years old,
recently retired, and challenged to take his medications as prescribed. Occasionally, flashbacks and nightmares trouble Bob; however,
his main reason for seeing Judy is to learn how to adhere to his prescribed medication regimen and stop imbibing whiskey nightcaps.

Judy has assessed Bob’s readiness for change, and she believes the person-centered, directive method of MI will help Bob be
adherent and alcohol free at bedtime. This week marks the third time Judy and Bob have met. Bob is aware of the five principles of
MI that Judy anticipates incorporating into their therapy sessions: roll with resistance, express empathy, avoid argumentation,
develop discrepancy, and support self-efficacy.

During their first session, Bob blamed his wife’s nagging as the reason why he drank alcohol and forgot his
medication. Judy did not argue with Bob; she simply involved him in a process of empathetic and respectful
problem solving. In session two, with no coercion whatsoever, Judy asked Bob what was bad or not so good
about his nonadherence and nightcaps. They explored his thoughts, and Judy acknowledged small positive
steps that Bob appeared to have been taking since they first met. This week Judy elicited more information
from Bob about what strategies he thought would work, and she sensed that he understood what it would take
to change his medication and drinking behaviors. Already, in 3 weeks’ time, Judy sees progress. Last week,
Bob asked his wife to assemble his weekly pill box and place it on his bedside table, along with a small glass of
cranberry juice. MI seems to be working.

Motivational Interviewing

Clinical social workers who work with people in recovery have the full range of therapeutic techniques at their
disposal. However, through research and practice experiences, it has become evident that a technique called
motivational interviewing is especially effective in work with substance users.

Motivational interviewing grew out of the “stages of change” (or transtheoretical) model, which is based on
empirical research (Prochaska & DiClemente, 1982). These are the five stages of change through which the
client moves with the assistance of the therapist:

1. Precontemplation (not yet acknowledging that there is a problem behavior requiring change)
2. Contemplation (acknowledging there is a problem but not yet ready or sure of wanting to make a

change)
3. Preparation (determination: getting ready to change)
4. Action (willpower: changing behavior)
5. Maintenance (maintaining the behavior change) and/or relapse (returning to older behaviors and

abandoning the new changes)

The concept of motivational interviewing evolved from experience using this five-stage model in the
treatment of people who are problem drinkers. Miller and Rollnick (2013) define motivational interviewing

436

as a client-centered, focused, and goal-oriented counseling style for eliciting behavior change by helping
clients explore and resolve their ambivalence about continuing to use the substance. On the one hand, clients
have come to enjoy using the substance, at least for a short time while the positive effects are strongest; on the
other hand, they have come to recognize that habitual use of the substance is creating problems in their lives.
The key to using motivational interviewing is to follow the client’s lead and use the most natural skills possible
to allow the client to open up. Those skills include warmth, empathy, and reflective listening.

Alcohol and Narcotics Anonymous

Groups are essential for the recovery of individuals with addictions and their families, and that is part of the
reason alcohol and drug treatment centers are successful. While at a treatment center, participants spend some
time being counseled one on one and a lot of time attending group meetings. Group therapy and addiction
treatment are natural allies. Members of groups can reduce their own isolation, and support and help others
who are recovering. Group participation helps people grow and be more healthy and creative as a result of the
natural interpersonal process that occurs in groups. Research at Crossroads Centre Antigua, an international
drug and alcohol treatment center, found that people who completed a 4-day program incorporating learning
materials, workshops, group sessions, and individual counseling sessions, along with opportunities for
interested family members to participate, experienced significantly improved recovery (Martin, Lewis, Josiah-
Martin, & Sinnott, 2010). In other words, people who participate fully in group work at a treatment center
tend to abstain from using their problematic substance longer than people who have participated in other
kinds of treatment.

One way of quitting addiction and entering recovery is attending Narcotics Anonymous (NA) or Alcoholics
Anonymous (AA), which are both 12-step programs. No judging occurs in these programs. NA uses AA
principles that focus on “working the 12 steps.” Twelve-step programs involve admitting to having a serious
problem, recognizing there is an outside (or higher) power that could help, consciously relying on that power,
admitting and listing character defects, seeking deliverance from shortcomings, apologizing to people you
have harmed, and helping others with the same problem.

Al-Anon Family Groups are related programs. The families of users share their experiences, strengths, and
hopes in an effort to solve common problems. Like AA and NA, Al-Anon is not allied with any sect,
denomination, political entity, organization, or institution. There are no membership dues, and the fellowship
is self-supporting through members’ voluntary contributions.

Needle-Exchange Programs

Needle exchange is a controversial intervention for reducing the transmission of HIV among those who inject
drugs such as heroin. For one thing, needle exchange does nothing to treat the addiction itself. To some, it
also seems to condone the use of injectable drugs. However, HIV prevention is relatively cheap. For the price
of a condom or a sterile needle, lives and several thousand dollars in health systems costs from caring for a
person living with AIDS can be saved (Bowen, 2012).

437

Needle exchange programs are examples of harm reduction; they reduce harm by preventing drug users from
contracting diseases from sharing needles.

Source: Photo by Joe Mabel/https://creativecommons.org/licenses/by/3.0/us/legalcode

The support and understanding of others are needed in recovery.

Source: John van Hasselt – Corbis / Contributor / Getty Images

Methadone Treatment Programs

Methadone is a synthetic opioid mostly used to treat heroin and prescription opioid addiction. It can be used
to detoxify people challenged with opiate addiction or to maintain a person abusing substances on a stable
dose so he or she can live a safer and more functional life. Its efficacy has always been hindered by negative
stigma related to morality.

Since methadone’s development in the 1960s, researchers have extensively scrutinized methadone
maintenance treatment. Studies consistently find that it is more successful than other treatment models in the
reduction of opiate/opioid misuse, transmission of HIV/AIDS and Hepatitis C, and criminal arrest and
conviction rates. Nevertheless, methadone maintenance treatment is viewed negatively by the general public
and vastly underused.

438

Diversity and Substance Use and Treatment

All kinds of people misuse or become addicted to drugs, alcohol, and other substances and behaviors;
however, those who are more privileged members of society may find it easier to afford or hide their
condition. They are also likely to be treated more leniently by the criminal justice system. Here are some other
ways diversity affects both substance use and addiction and its consequences.

Age. When youth or adolescents experience substance use problems, family involvement is very
important because parents have to finance and drive their children to care. The age at which adolescents
begin using alcohol and drugs is a powerful predictor of later problems, especially if they begin using
before age 15. Youth start with alcohol and cigarettes, then progress to marijuana and other drugs.
Teens use mostly alcohol and tobacco (cigarettes). Those between ages 18 and 25 most likely use illicit
drugs. Older adults use substances also, but they are underrepresented in treatment settings because
health care providers tend to miss assessing substance use behaviors in this population. Treatment
should be supportive and slower paced for older adults. Outpatient treatment programs work best for
older adults when the programs are situated in settings the seniors already frequent. Older adults often
experience immense grief and loss surrounding their diagnosis of substance use and can benefit from
reminiscing or guided autobiography.
Class. Despite what you may have heard, people who are homeless and use substances make up a small
proportion of people with alcohol and drug problems. It is true, however, that those people with lower
socioeconomic status frequently face barriers to recovery that include unemployment, health disparities,
and unsafe living conditions—all of which tend to create despair and make people in this socioeconomic
stratum even more likely to relapse. Women who are poor might be able to afford only inexpensive
crack, whereas affluent adults who are older with significant life savings have lots of disposable income
to spend on expensive drugs and alcohol.
Race/ethnicity. African Americans, Latinos, and Native Americans are frequently seen in drug treatment
settings—and because of the higher rates of poverty among these groups, they are especially likely to be
seen in public facilities. Although their treatment may be just as effective as that received in private
settings, it also suffers because members of oppressed racial and ethnic groups may distrust agency
professionals, especially if they are mostly white. Although substance use treatment should not center on
race or ethnicity, it is important for the social worker to understand the role of culture, history,
oppression, and ethnic pain. Additionally, substance use and chemical dependency often involve
multigenerational factors (e.g., introduction to substances) as well as genetic predisposition. It is also
important to realize that recent immigrants face a higher risk for drug and alcohol use and misuse than
do other ethnic group members who have been settled in the United States. The stress of acculturation
has been related to delinquency, drug use, and mental illness (Davis, 2008). Unfortunately, there is a
tendency for minority groups to be punished more often for their substance use compared with the
wider majority population. Some Americans are shocked to learn how heroin use and addiction have
sharply increased among whites in the United States (Reaney, 2017).
Gender. Females who struggle with substance use issues typically have more frequent and serious health

439

outcomes from addiction than males do and more psychiatric issues (such as depression), and—except
for African American women—they are more likely to live with a partner or spouse who has a substance
use problem (Blume, 1992; Mirick, 2014). On the positive side, women, along with older drivers, have
fewer alcohol-related fatal crashes. Women make up 30% of the substance use recovery population in
North America, but in the United States, 92% of women who need treatment for alcohol and drug
problems do not enter a recovery program, for multiple reasons (Young, 2010). A main reason for this
lack of treatment seeking is that women need to have their situation considered in a broader context—
family, extended family, support systems, economic and social environment, gender, and culture.
Women have gender-specific treatment needs, yet few specific treatment models (Young, 2010).
Sexual orientation. Historically, gay and bisexual men have been identified with using “club drugs” such
as ecstasy, which lessens their inhibitions and increases their drug use. They were thus also at a higher
risk of contracting HIV/AIDS than are other groups. Lesbian, gay, bisexual, questioning, and
transgender (LGBQT) clients may go unrecognized in addiction treatment centers, especially if they are
assumed to be heterosexual. Recognizing LGBQT clients is imperative to gain their trust and
willingness to seek health care, mental health services, and addiction treatment. Historically, LGBQT
populations have lacked places to socialize, and women’s particular issues have been unattended to. In
the 21st century, however, gay bars exist out in the open and the media are more accepting of people
who identify with the LGBQT community.

440

Advocacy and Substance Use Disorder

Social workers require an ecological perspective to work effectively in the substance use field. They will not
only focus on a person’s addiction or substance use but also help clients in relation to their family, their
neighborhood and social support system(s), prevailing cultural attitudes and policies, and on the cosmic or
spiritual level. Social workers trained in substance use and addiction may find themselves advocating for
clients directly in the process of case management, individual and group therapy, and family counseling. Social
workers need to learn about SBIRT and be skilled in the use of motivational interviewing (Liberto & Fornili,
2013; Littrell, 2011). They will also engage in advocacy for jobs and housing, community development of
resources, educating, policymaking, and sometimes a combination of these.

441

Economic and Social Justice

People who have great insurance coverage can afford nice, private, for-profit addiction treatment centers.
Those without good coverage must resort to public or government-sponsored organizations. When clients do
not have insurance, social workers advocate in such a way that the clients can better access services and thereby
obtain improved treatment. Social work advocates also help clients understand insurance options and apply for
insurance.

For clients who present with co-occurring disorders and misuse of multiple substances, the social work
treatment field is shifting to a more holistic approach. Health care reform in the United States is encouraging
integrated and integrative treatment by linking treatment for addiction and other behavioral health conditions
into primary care practices and federally qualified health centers (Quanbeck et al., 2014). Consequently, social
workers will be required to have the skills and knowledge to provide treatment for substance use disorders and
additional co-occurring mental health conditions simultaneously.

442

Supportive Environment

The physical place where people live, geographically, affects their initiation into drug use. To ameliorate the
effects of environmental factors, social workers can serve on planning boards that make decisions about where
drug rehabilitation centers will be located. They can also advocate for uninsured clients to gain access to
integrated community health centers.

Additionally, one’s place of residence influences potential access to substance use services. City dwellers may
be close to teaching hospitals, clinics, and addiction treatment facilities. Residents in rural areas may have
extremely limited access to such services.

443

Human Needs and Rights

People need and deserve respect and acceptance, despite their substance use. People with substance use issues
need to know that drug use and addiction is a disease and not a character defect. Professional social workers
play vital roles in helping family members understand what the detoxification and recovery processes are all
about and what will likely happen to their relative who requires medical treatment by physicians and follow-
up meetings with a school, the courts, or other personnel.

At the same time, people being treated for substance use and addiction have the right to know that over the
long term, drug use and addiction will likely result in physical harm, behavioral problems, and association with
other people who also use drugs. Along with human rights, personal risk requires consideration.

Nevertheless, social workers need to acknowledge that people have the right to go uninsured, misuse over-the-
counter drugs, or refuse to take antidepressant medications, if they want to. However, when people’s choices
risk the endangerment of others, professionals must intervene. A professional social worker is responsible for
reporting cases when he or she sees that children are at risk for maltreatment due to a parent’s addiction, or
senses that adults are a danger to themselves or others.

Time to Think 10.4

Imagine that someone in your family or a close friend uses substances or has an addiction. You are sensitive to this person’s rights as
a human being but also aware of the physiological, mental, and social consequences of his or her behavior. You have already tried
hard to help. At what point would you decide not to try any longer?

444

Political Access

Legalizing drugs in the United States is far from an innovative idea. Consider how long public debates have
been addressing the legalization of performance enhancing drugs in sports. Lance Armstrong’s case, for
instance, forces us to consider a philosophical problem that torments those who love watching Tour de France
bicyclists and MLB (Major League Baseball) and NFL (National Football League) players. Promoters,
sponsors, leagues, and advertisers all dangle incentives for athletes who can reach record-breaking
performances.

Debates also focus on how to handle border police responsible for catching drug dealers at the Mexican
border. Politicians and scholars, including social workers, have for decades articulated arguments to legalize or
decriminalize drugs; however, they have failed to address the issue of drug trafficking and the rise of
international markets for illegal drugs (Jenner, 2011). The NASW (2013) Social Justice Brief titled “A Social
Work Perspective on Drug Policy Reform: Public Health Approach” reminds social workers that they are
integrally involved with the criminal justice service delivery continuum and should therefore serve as
“stakeholders in the national movement to bring about reforms in how drug-related offenses are processed” (p.
1; see also Gorin, 2001). This brief also states that by virtue of social work’s historical advocacy for people
with limited resources and no political power, social workers must be involved in drug policy reform. In
addition to advocacy, social work professionals are responsible for conducting objective research and studying
the pros and cons of legalization, as well as noncoercive methods to prevent drug abuse.

The Trump administration launched a campaign against heroin and the pain-pill epidemic, which causes a
staggering 52,000 overdose deaths a year. However, myths about addiction must be addressed if lives are to be
saved. At least four politically correct myths about addiction require a clear-headed reassessment: (1) drug
addiction is a chronic illness like Parkinson’s; (2) people with addictive disorders can’t stay abstinent; (3) don’t
hurt the feelings of people with addictions—it might discourage them from seeking treatment; and (4) the
more treatment the better.

445

Your Career in Substance Use and Addictions

Job growth for substance use social workers is expected to be much higher than the average for all careers
through 2020. This increase is partly thanks to new laws that send people who use drugs to treatment
programs instead of jail (Peternelj-Taylor, 2008). Employment growth will also be driven by an increased
overall need for health care. Returning veterans with mental challenges such as posttraumatic stress disorder
(PTSD) are at risk of drinking more alcohol to cope with their stresses; Veterans Affairs may consequently
increase job opportunities for mental health and substance use social workers.

Additionally, a surprising number of baby boomers are abusing not only alcohol but also illicit drugs such as
cocaine, heroin, and marijuana (Reardon, 2012). Social workers have a role to play in counseling some baby
boomers who have long “experimented” with drugs and are now experiencing the stresses of transitioning into
older adulthood. Aging baby boomers may also need to be updated on recent research into the mechanisms
and consequences of using these drugs.

Regardless of the population being served or the setting in which treatment takes place, social workers should
become familiar with the programs of SAMHSA. SAMHSA disseminates national data on the characteristics
of people admitted into treatment and their substance use problems. Substance use social workers also benefit
clients greatly when they possess a working knowledge of psychopharmacology and keep up-to-date with the
vocabulary that describes a plethora of mind-altering substances. Understanding this new terminology, as well
as neuroscience and the dynamics of co-occurring substance use, misuse, addiction, and dependence, is
essential to effective practice.

446

Certifications in Substance Use: CADC and LADC

In 1970, each state was required to create a state alcohol authority (SAA) and a single state authority (SSA)
for drug abuse to manage block grants and plan for the delivery of treatment services. For treatment programs,
complying with state treatment standards for substance use may take the form of licensure, accreditation, or
certification. In many states, treatment programs that have not been certified, licensed, or accredited are not
eligible to receive state or federal funding. Similarly, insurance companies often will not pay for treatment
services if programs are not licensed, certified, or accredited by the state. Additionally, some states require
certification or accreditation for certain programs, such as residential treatment, opioid treatment programs, or
other programs, such as driving under the influence (DUI), while certification is voluntary for other programs,
such as out-patient treatment. State treatment standards generally address governance, fiscal management,
personnel, statistical reporting, client rights, client case records and quality of care reviews, and environmental
sanitation, safety, and prevention.

SAMHSA documentation contains a national overview of state-by-state information on licensing,
certification, and credentialing standards for alcohol and drug treatment facilities, programs, counselors, and
prevention professionals. Information covers the approval process for each state’s substance use program as
well as national accreditations accepted in lieu of state accreditation.

The U.S. Department of Health and Human Services oversees SAMHSA. SAMHSA publishes a document
entitled “A National Review of State Alcohol and Drug Treatment Programs and Certification Standards for
Substance Abuse Counselors and Prevention Professionals,” and it may be retrieved at
https://www.samhsa.gov/sites/default/files/fbci_counselor_standards.pdf. The CADC (Certified Alcohol and
Drug Counselor) and LADC (Licensed Alcohol and Drug Counselor) are the most common credentials
obtained by people who want to work as substance use counselors. These credentials recognize specialty
training in addiction. Oral and written exams are involved and applicants must pass both. The exam focuses
on 12 core competencies of addiction.

The CADC, is provided by Boards of Substance Abuse Counselors. States like Massachusetts have three
levels of CADC licensure: CAC, CADC, and CADC II. The LADC is provided by the Bureau of Substance
Abuse Services (BSAS). There are three levels of said licensure in Massachusetts: LADC Assistant, LADC I,
and LADC II. The CADC II and LADC I require master’s degrees in behavioral science and additional
special education in ethics and drugs and alcohol use. Behavioral science graduate degrees can be in a range of
disciplines (e.g. anthropology, art/dance, criminal justice, divinity, gerontology, human services, social work,
etc.).

Employers often prefer to hire people with specialty training, as third-party reimbursement is increasingly
desired and available for people who hold licenses or certifications. In Illinois, two certifications exist—the
CADC and the CRADC (Certified Reciprocal Alcohol and other Drug abuse Counselor). In New Jersey, the
CADC and LADC credentials are recognized, and the primary difference is that the LADC is allowed to
conduct unsupervised independent practice. Both can make assessments, but the CADC cannot make

447

diagnoses. Licensed Clinical Alcohol and Drub Counselors (LCADC) must possess a graduate degree, take a
written exam, and keep their biennial license current and renewed.

Summary

Determination, patience, and courage are the only things needed to improve any situation.

Peter Sinclair

Substance misuse and addiction is a chronic disease of circuitry in the brain related to reward, motivation, and memory. Addiction
affects neurotransmission and thus the ability of those who have the disorder to control their own substance use, especially when they
are under the influence. Therefore, it is crucial that substance use social workers possess an understanding of the neurobiology of
addiction.

Recovery from substance misuse can be a lifelong journey and people often require support. People in recovery require support lest
relapse occur as a response to almost any kind of stressor. Social workers must be aware of how substance use affects and costs the
person, the family, and the community in so many ways, including loss of work, impaired physical or mental health, increased crime
and violence, reduced quality of life, and more. Social workers must increase their understanding of behavioral or process addictions.

Substance use social workers collaborate with multidisciplinary teams to offer people with substance misuse problems psychotherapy,
access to treatment programs, and help with drug-related problems in relationships and life. Social work professionals have a unique
role and skill set to offer the multidisciplinary team. They consider the person in her or his environment, advocate for timely access
to rehab treatment and follow-up community services, and offer hope. Skills in motivational interviewing and an understanding of
12-step principles and change processes help social workers garner their clients’ trust and encourage their growth.

448

Top 10 Key Concepts

addiction
alcoholism
codependency
harm reduction model
motivational interviewing
recovery
substance misuse
Substance Abuse and Mental Health Services Administration (SAMHSA)
substance use
12-step approach

449

Discussion Questions
1. In the vignette at the beginning of the chapter, Clayton is successful as a substance misuse and addiction counselor but has had

less success in keeping his son from misusing substances. How would you explain this discrepancy?
2. How does substance use and addiction affect a family system and neighborhood?
3. Why is prevention so important in the field of substance use treatment?
4. What role does social support play in helping people cope with addictive substances?
5. What is your opinion of needle exchange and methadone treatment programs? For you, do the moral issues they raise outweigh

their effectiveness? Why or why not?
6. How can the health beliefs and voices of people using addiction services be better understood and advocated for, regardless of their

cultural backgrounds?

450

Exercises
1. Locate research articles or resources that examine how social workers are working to understand a particular substance use or

addiction, such as alcoholism, drug use, or food addiction. What seem to be the most effective interventions to date?
2. Peruse the SAMHSA website and reflect on the array of information available there. What part of the website would be valuable

to ordinary people? What part would be valuable to a professional in the field of substance use? Does this entity seem to be a
worthwhile expenditure of public funds? Why or why not?

3. Examine the community where you live or attend school, and assess what substance use and addiction programs exist. What are
they called and where are they located?

4. Every now and then, the media run exposés on 12-step programs. Research the social work literature to discover how effective 12-
step programs are.

5. Watch Johann Hari’s TED Talk entitled “Everything You Think You Know About Addiction Is Wrong”
(https://www.ted.com/talks/johann_hari_everything_you_think_you_know_about_addiction_is_wrong/transcript?language+en).
Then discuss to what extent you agree with Hari’s conclusion that “the opposite of addiction is not sobriety . . . but connection.”

Online Resources

NJPN (http://www.njpn.org/initiatives/addiction-training-and-workforce-development-program/cadclcadc-trainings):
Provides information about the CADC certification
National Institute on Alcohol Abuse and Alcoholism (www.niaaa.nih.gov): Conducts research and promotes understanding
about alcohol use
National Institute on Drug Abuse (www.drugabuse.gov): Conducts research and promotes understanding about drug abuse
American Addiction Centers (http://americanaddictioncenters.org/behavioral-addications): Provides information about
process addictions
SocialWorkLicensure.org (www.socialworklicensure.org/types-of-social-workers/mental-health-substance-abuse.html):
Provides information about mental health and substance use social workers
Substance Abuse and Mental Health Services Administration (www.samhsa.gov): Agency within the U.S. Department of
Health and Human Services that aids programs and efforts to help people with substance use or mental illness problems and
gives money to programs for research and demonstration projects

Student Study Site

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

451

Chapter 11: Helping Older Adults

Source: iStock Photo / shapecharge

452

Learning Objectives
After reading this chapter, you should be able to

1. Understand the variations in normal aging.
2. Appreciate the biopsychosocial-spiritual and family aspects of aging across the life span.
3. Describe gerontological social worker practice and policy roles.
4. Identify and understand available services and policies that relate to older adults.
5. List at least three ways the aging population is changing American society.

Emilee Adores Gerontological Social Work

Emilee warmly greeted the family members as they arrived to the caregiver support group at The Royal Suites, the assisted-living
and long-term care nursing home where she works. Virtually all the attendees at these group meetings are experiencing stress
because their spouses or parents are experiencing some type of dementia or neurocognitive challenge. To begin this week’s session,
Emilee wisely distributes handouts on abuse of older people and resource lists for respite care while the caregivers take a little time
for themselves. Emilee well realizes how quickly stress can escalate into mistreatment.

Since graduation as a BSW-trained social worker who also minored in gerontology, Emilee has had no problem finding work with
older adults. In Sun City, Arizona, Emilee worked in sundry assisted-living facilities. Now at a facility in Vermont, she uses
comparable skills and has initiated new training programs for the facility’s certified nursing assistants and other interested staff. As
the social work director, Emilee’s main responsibility at The Royal Suites is to keep the facility census full and meet the
biopsychosocial-spiritual and safety needs of residents. Emilee’s five major roles are as a decision-making and transition coordinator,
resident advocate, mental health assessor and counselor, family social worker liaison, and care planner (Koenig, Lee, Fields, &
Macmillan, 2011). She competently provides information and referral resources to family members who know little about all the care
options for older adults with dementia and other neurocognitive challenges. In addition, she also coordinates support groups,
supervises students, and collaborates in marketing efforts.

To provide the best possible information to family members, she stays updated on Medicare, Medicaid, the Affordable Care Act
(ACA), President Trump’s repeal and replace efforts, and insurance changes by visiting the Centers for Medicare and Medicaid
Services website, attending online webinars and statewide conferences, and reading news blasts from AARP (formerly the American
Association of Retired Persons) and several aging-related online forums to which she belongs.

Emilee fortifies the image and presence of her workplace by providing tours to the public and holding educational lectures for staff
and community social workers that award them continuing education credits. Speakers from the nearby university’s Center on
Successful Aging spark lively discussions at breakfast meetings about the latest concepts in gerontology, such as culture change,
assistive technology, guided autobiography, slow medicine, and palliative care.

Emilee feels fortunate to have grown up with all four of her grandparents and her two great-grandmothers, who lived to be 99.
Fortunately, Emilee enjoyed many positive images of active and successful aging as she observed her energetic and engaged
grandmothers and her witty, intelligent, and fun-loving grandfathers.

Today’s cohort of older adults has a variety of expectations about what the experience of aging will bring. In
part, those expectations are generational (see Exhibit 11.1 for a breakdown of the generations in the United
States). Generation X, who are in their mid-30s, 40s, and early 50s at this point, are typically just beginning
to think about their lives in older adulthood. They feel considerable anxiety about their finances in retirement.
The “boomers,” the generation born between 1946 and 1964, are the ones now entering older adulthood.
Their expectations are quite different from those of their predecessors, the “traditionalists.” Traditionalists
have often been surprised that they lived so long and so well, given their parents’ problems with aging,
relatively early demise, and financial struggles in old age. Boomers, on the other hand, expect to remain active

453

and healthy well into their proverbial golden years, with good health care and social support. Consider the
images of happy, engaged aging currently portrayed in the media.

There are some grimmer realities, however. A large number of very old single or widowed women who are
childless live in nursing homes. Increasing numbers of older people are continuing to work out of necessity.
Although older Americans tend to be among the wealthiest groups in our nation, some of them are among
the most economically disadvantaged. Older adults are working longer. Obesity rates among older adults have
been increasing, standing at about 40%, thereby putting more older people at risk for chronic disease and
disability. Yet, poverty rates for Americans age 65 and older have dropped sharply over the last 50 years, from
30% in 1966 to 10% today (from Population Reference Bureau Data at
http://www.prb.org/Publications/Reports/2015/unitedstates-population-bulletin.aspx).

This chapter urges you to view aging realistically and positively. It explores the realities of the biological aging
process, defines aging and gerontology, explores psychosocial-spiritual issues surrounding older adulthood,
and identifies policies and services important to older adults. Both specialized gerontological social workers
and generalist social workers across multiple agencies, organizations, and fields of practice will be required in
growing numbers to fulfill the care needs of older adults and their families and caregivers.

It is important to keep in mind that we are all aging and would like to maintain our independence as long as
possible. To maximize older adults’ independence, social workers must join other specially trained
professionals to create innovative and responsive policies, programs, structures, and practice modalities.

Time to Think 11.1

What does it mean to be “old” or an “older adult”? Why do older people not want to be labeled as “elderly” or “senior citizens”? Why
do you suppose television, films, and social media show mostly younger leading characters and magazine ads mostly feature young,
sexy people on their covers?

454

Aging and Older Adults

American society has not fully come to terms with the meaning of aging, the process of change that occurs in
an organism during its life span. More precisely, we are concerned about senescence, which is the gradual
decline of all organ systems, leading inevitably to death. Thus, aging at its core involves a confrontation with
one’s own mortality.

Because American culture fears aging and death, we often devalue older adults. Social forces such as age
discrimination and ageism, even among professionals, make the process of biological aging sometimes seem
more negative than it needs to be (Moody & Sasser, 2012). At the same time, optimists think that medical
science will soon find a way to delay senescence. Marketers play on that hope, plying us with cosmetics, elixirs,
and procedures that promise to postpone aging. And, indeed, senescence often does not stop individuals from
enjoying life.

Social work with older people encompasses both the positive and the negative aspects of aging. It often
involves making health, housing, and social security systems work for clients, and ensuring that systems
respond appropriately to older people’s needs. It may also mean helping older people and their families
manage issues of chronic illness, financial and social stress, and death and dying.

Social workers who specialize in this field of practice may call themselves gerontologists. Gerontology is the
comprehensive study of aging and the problems of older adults. Gerontologists are multidisciplinary, usually
combining expertise in biology, psychology, and sociology. Gerontology professionals work in health care,
government, nonprofit agencies, the business community, and university settings.

455

Meanings of “Aging” and “Old”

When people in the United States turn 50, they typically receive an invitation for membership in the AARP.
It is something of a rite of passage for adults, signifying they are entering the years when their perspective on
life might begin to change and others might start to consider them old. AARP is one of the most powerful
lobbying organizations in America, taking up such causes as the preservation of social security for future
generations. Its magazine covers feature celebrities who just turned 50, providing visual proof that despite
fame or fortune, all humans become chronologically older. But the stories of vibrant 50-plus individuals inside
the magazine point out that aging is in part an attitude.

Another marker of entering old age was established by the Social Security Act of 1935, which set 65 as the
official retirement age and the age of eligibility for Social Security retirement benefits. (Changes to the law are
gradually increasing the age of full eligibility, however; some people will reach full eligibility at age 66 or 67.)
Scholars have mistakenly credited German chancellor Otto Von Bismarck with spreading the idea that old
age begins at 65, because in 1889 he introduced a pension schedule in Germany for those 65 and older
(Hayflick, 1994). However, recent research reveals that it was well after Bismarck died, in 1916, when the
retirement age in Germany was reduced to 65 years (von Herbay, 2014).

Being defined as “old” may be desirable or undesirable, depending on one’s culture and values. Some people
dread the approach of their 65th birthday (or their 50th or 70th or whichever birthday seems to them to mark
the beginning of old age); others look forward to retirement, relief from many of the more burdensome family
and work obligations, and all the “senior discounts” that will be available to them.

Aging is in part an attitude.

Source: iStock Photo / Rawpixel

Otto Von Bismarck is often incorrectly attributed with establishing 65 as the age of retirement.

456

Source: Photo by P Loscher and Petsch / Wikimedia Commons

This range of responses is another hallmark of aging. Developmental scholars have found that there is more
variation, in terms of health and human development, among older people than among any other age group.
Two-year-olds predictably have similar developmental experiences; however, 65- or 75-year-old people widely
vary in their employment situations, family responsibilities, and health experiences. Some retire, while others
assume encore careers and embark on creative new journeys and adventures. Although many older people live
alone or with only a spouse, others may become responsible for the care of their grandchildren or children
who are permanently impaired physically or mentally, or struggling financially (preferably not permanently).
Although about 80% of older adults will likely have at least one chronic condition at some point, many control
their conditions with medication, and 20% age with older but still-healthy bodies and minds (Centers for
Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,
2011).

Spotlight On Advocacy

457

Dan Buettner Publishes Lessons for Long Life
One way for gerontological social workers to advocate for lifestyle changes in clients is to refer them to Dan Buettner’s research.
Buettner is an explorer and educator who has authored The Blue Zones: Lessons for Living Longer From the People Who’ve Lived the
Longest and Thrive. He also served as keynote speaker for the Gerontological Society of Aging annual meeting for professionals in
2014.

For The Blue Zones, Buettner received funding from the National Geographic Society to investigate where in the world people lived
the longest and why. On the sleepy Greek island of Ikaria, one in three Ikarians reach age 90. This group showed virtually no
Alzheimer’s disease or other dementia. As he interviewed 90- and 100-year-old people, he found 13 likely contributors to Ikarian
longevity. So here is one possible “fountain of youth formula”:

Graze on greens.
Sip herbal teas.
Throw out your watch.
Nap daily.
Walk wherever you’re going.
Phone a friend (maintain strong social connections).
Drink goat’s milk (rich in the blood-pressure–lowering hormone tryptophan).
Maintain a Mediterranean diet.
Enjoy some Greek honey.
Open the olive oil.
Grow your own garden (or find farmers’ markets).
Get religion.
Bake bread (the island’s sourdough bread is high in complex carbohydrates and may improve glucose metabolism and stave
off diabetes).

1. What additional lessons do you know of that might contribute to a longer and healthier life?
2. How can social workers use this information to educate and help others?

458

Stages of Older Adulthood

Gerontologists use special terms to refer to age groups among older adults, in an attempt to categorize some
of the variations they encounter. Exhibit 11.2 summarizes these categories. The oldest-old are usually frail
and need the most assistance. But the young-old and middle-old tend to be able to live independently and
function well, despite the possible need for health, mental health, and social services to maintain and
maximize their independence and functioning.

Additional labels that have entered our vernacular, related to aging, are centenarian and supercentenarian.
Centenarians are people who arrive at age 100. One in twenty-six baby boomers are expected to live to age
100, and legions more will likely reach their mid- to late 90s. Supercentenarian is a more recent descriptor for
a person age 110 or over.

459

Longevity

Gerontologists also distinguish between the terms life expectancy, life span, and longevity:

Life expectancy is how long on average a person is expected to live at a given age (see Exhibit 11.3).
Life span is a person’s lifetime, the number of years a person actually lives.
Longevity refers to living an active life longer than the average person.

Exhibit 11.1 American Generations and Their Expectations of Older Adulthood—Fiction or Reality?

Source: Kruse (2005) and Novak (2014).

Most people wish to experience longevity—that is, to have a life span that is beyond their life expectancy.
Insurance companies are expert tabulators of life expectancy, and they, among others, provide online
calculators that can help estimate your likely life span.

Longevity is partly a matter of your genetic heritage (how long did your grandparents live?) and partly a choice
you make by the way you live your life. The influence of your poor choices can actually be tabulated.
According to the Population Health Institute, when calculating mortality rates, almost one third of the
influencing factors are health behaviors, medical care, socioeconomics, and physical environment. So if you
want to live a long, healthy life, you can choose to live in a low-stress, low-pollution environment; eat nuts,
fruits, and vegetables; drink red wine; and work out—or you can choose to smoke, binge drink, eat unhealthy
food, and engage in other risky behaviors.

Exhibit 11.2 Subcategories of Older Adults Recognized by Gerontologists

460

Exhibit 11.3 Life Expectancy at Birth, By Race and Sex: 1970–2012

Source: Arias, Heron, and Xu (2016).

Time to Think 11.2

How long do you expect to live? What do you know about your family medical history or the geographic environment where you
live? Do you have “good genes” and live in a place where people thrive and have a long life expectancy? Are your personal habits
conducive to longevity?

461

An Aging Populace

From the 19th century to the present, improvements in sanitation, diet, and medical care have led to a
dramatic increase in life expectancy. At the same time, birth rates and death rates are declining. As a result,
the population of older people as a percentage of the total population has been growing

The growing number of people who are old is very visible in the United States and worldwide. This “aging of
the population” is concerning to political leaders, government planners, and average citizens. It is affecting all
kinds of social institutions, including families, education, the workplace, and health and mental health, as well
as the leisure and hospitality industry. Surrogate decision makers for hospitalized older adults also require
increased consideration, in the form of high information disclosure and frequent communication, as they are
increasingly needed to make medical decisions for the nearly 40% of hospitalized patients who have impaired
cognition (Naik, Teal, Pavlik, Dyer, & McCullough, 2008; Torke et al., 2012).

For example, the rapidly growing population of adults aged 65 and older is outpacing the U.S. current health
care system’s capacity to care for them. Each day between now and 2030, an average of 10,000 people will
turn 65. Without immediate action, the health care workforce will lack the capacity, both in size and ability,
to meet the needs of this number of older Americans (Bragg & Hansen, 2011).

During the next three to four decades, there will also be a significant increase in certain vulnerable populations
of older adults in the United States—particularly the oldest-old (people 85 and over), unmarried women,
women who live alone with no children or siblings, and older racial minorities who live alone with no nearby
kin. The number of older adults and the oldest-old who will require long-term care is projected to rise
astronomically during the ensuing decades.

462

Gerontological Social Work Practice

Social work practice with older adults actually includes two specialties:

Gerontological social work is based on biopsychosocial-spiritual knowledge of the aging process.
Gerontological social workers enhance developmental, problem-solving, and coping abilities of older
people and their family members; promote effective and humane operation of delivery systems that
provide services and resources to older adults and their families; link older clients with systems that
provide them with opportunities, resources, and services; and enhance the creation and improvement of
social policies that better people’s functioning across their life course (Berkman, Dobrof, Damron-
Rodriguez, & Harry, 1997).
Geriatric social work is grounded in interventions with older adults who have health concerns; geriatrics
is thus focused on physiological changes in aging and on health care. Geriatric social work practice
mostly centers on family caregiving, because about 80% of the care for older adults is rendered by
informal support systems (Rizzo & Rowe, 2006). Geriatric social workers also provide community care
via hospitals or facilities (e.g., long-term care, assisted living, respite care, dementia care), home
environments, and communities.

463

Evolution of Gerontological Practice

Gerontological (and geriatric) social work practice is a relatively new specialty. The social work profession
formally recognized the need for specific gerontological or geriatric knowledge in the mid-20th century. In the
late 1960s and early 1970s, the social work profession finally began to consider older adults a target population
that required specialized knowledge and training (Damron-Rodriguez, 2006). Closer ties between social
workers and medical professionals dealing with older people took a bit longer. In 1995, the Bureau of Health
Professions held a National Forum for Geriatric Education that for the first time included social work. Soon
thereafter, the John A. Hartford Foundation began to fund social work research projects to improve the
medical care of older people (Berkman et al., 1997). The Hartford funding has positively influenced the fields
of geriatrics and gerontology, because social work research has yielded a great deal of new information about
useful interventions, resources, and advocacy strategies (Greenfield, Morton, Birkenmaier, & Rowan, 2013;
Hooyman, 2006; Robbins & Rieder, 2002).

Over time, biological, psychological, and social science theories about aging have also evolved. They focus on
the social consequences of biological aging for older adults and for their families, communities, and society as
a whole. Exhibit 11.4 lists some theories of aging that help social workers avoid assumptions about aging, and
create better policies and practice interventions. Social work’s focus on human values is reflected in these
theories.

464

Social Work Roles in Gerontology and Geriatrics

As Exhibit 11.5 shows, gerontological social workers assume multiple and complex roles involving all levels of
practice: micro, mezzo, and macro. Social workers go to older adults’ homes to do assessments and provide
clinical counseling to individuals and families. They also work within institutions such as hospitals and
rehabilitation or residential settings, and throughout communities. Their primary role is to provide education
and training about aging and older adulthood, conduct support groups, make sense of medical diagnoses and
prescriptions, deliver counseling and case-management services, and advocate for environmental and
legislative changes. They might also design and facilitate intergenerational programs, such as an adopt-a-
grandparent program.

Exhibit 11.4 Theories of Aging

Source: Moody and Sasser (2017).

These are some of the specific direct, client-focused services they provide:

Help clients choose the best Medicare Part D plan
Tell families about adult day-care services and refer them to agencies that provide those services
Make referrals to adult protective services when they perceive that an older person is being abused or
neglected
Intervene in crisis situations and devise ways to navigate immediate solutions
Counsel older individuals experiencing grief over terminal diagnoses and offer grief or bereavement
counseling to families, often by providing links to hospice or chaplain services
Provide referrals to home health or respite care services and explain how to activate insurance coverage
for them
Provide (and help complete) applications for housing and transportation services and help coordinate
them

Geriatric social workers, in contrast, have a more direct role with clients and their families overall. They help
clients best when they participate as interprofessional and collaborative team members, with the client and
family at the center (see Exhibit 11.6). Social workers often observe, oversee, negotiate, and advocate for their
older clients’ relationships with family members, nurses, geriatricians (doctors), neuropsychologists, and
pharmacists. Social workers reinterpret for clients the medical diagnoses and prescriptions they get from
geriatricians and pharmacists. When dementia is suspected, social workers will link clients with a

465

neuropsychologist or home health nurse for additional assessment and assistance with activities of daily living
(ADLs), such as taking medicine, bathing, and preparing meals, as well as more instrumental activities such as
managing money, shopping, and housekeeping.

The provision of these services varies widely by client and client system. In their assessments, social workers
must continuously evaluate such factors as access, desire, and capability, and the interrelations of complex
phenomena in the lives of clients and their families:

Marital status
Living arrangements
Education
Labor force participation and economic dependency
Numbers and capabilities of the client’s children
Client’s home and its suitability
Resources, including income and insurance

Important questions include, “How educated is my older adult client?” “Does my client have children who live
nearby?” “Has my client been married?” “Does my client live in a clean and stable environment?” “Does my
client have savings and retirement income?”

466

Resources for Successful Aging

Active and successful aging are popular perspectives that resonate with gerontological and geriatric social
workers who already lean toward interventions based on strengths and resilience (Greene, 2002; Greene &
Galambos, 2002):

Active aging is becoming older but continuing to grow and participate in family, community, and
society.
Successful aging is becoming older but avoiding disease and disability, and continuing active
engagement in life.

Exhibit 11.5 Settings and Roles for Gerontological Social Work

Exhibit 11.6 Ecology of Geriatric Social Work

467

468

Source: National Institute on Aging (2011, May).

Social workers in these fields thus try to promote older adults’ self-direction and self-advocacy to inform the
social workers’ recommendations for community resources, programs, services, and policies for and related to
older adults. Such services fall into the subcategories of living spaces and places; day programs and activities;
and resource, discount, and benefit programs.

Living Options

Most older adults prefer to live at home as long as possible, perhaps until death. However, they may choose
instead to reside in a homelike environment that ameliorates some of the problems of living at home:

Assisted living: They are in their own unit but can gather with other residents for meals and recreation,
and are monitored for health problems.
Continuing care retirement communities: They can stay in one setting but move to more appropriate
living units if the level of health care and attention they require changes.
Nursing homes (intermediate or skilled level of care): They receive more intensive nursing care; some
nursing homes specialize in caring for people with Alzheimer’s disease.
Foster care homes, group homes, and Housing and Urban Development housing projects: Older adults who
have lifelong developmental or intellectual disabilities or are impoverished can live in an environment
suited to their needs.

Social workers help family members and older adults understand the culture of the setting and sources of
financial assistance to pay for the housing (especially for assisted-living and nursing homes).

Day Programs

For the majority of older adults who are able to stay in their homes, a multitude of daytime services and
opportunities exist that can help relieve loneliness and depression, and maintain health:

Clubs and volunteer programs
Congregate meals
Adult day-care centers
Fitness centers with special classes for older adults (e.g., Zumba Gold, ActiveForever strength training,
aqua aerobics)
Senior centers, which offer games, crafts, speakers, and day trips
Foster grandparent programs, which are intergenerational experiences that match elders with children
for mutually beneficial relationships

Social workers assess, coordinate, develop, intervene, and provide information and referrals to all these
community-type services.

469

One of the challenges of social work with older adults is honoring their strengths. One solution is to
encourage older adults to participate in ordinary activities that take advantage of the knowledge and skills they
have developed over a lifetime. Organizations such as SCORE, for instance, employ older people who have
had a business career to advise small-business owners. Another solution is to encourage participation in art
and creative work, which enhances social interaction and provides a sense of fulfillment. People of all ages
receive a boost from seeing an enjoyable result from their work, and older adults once again have the time to
pursue those kinds of activities. Creative work can also be a diversion from depression or difficulty (Payne,
2012, p. 128).

Benefit Programs

An assortment of community services exists for older adults. Social workers often help older people with
challenges and older adults who are very poor apply for services and entitlement programs to meet their living
requirements, such as food stamps; home health services; meals-on-wheels; nutrition programs; old age,
survivors, disability, and health insurance; ombudsman programs to investigate nursing home resident
concerns; property tax relief; respite care and rehabilitation services; and the special federal income tax
deduction for those over age 65. Social workers may also be able to help older adults find and secure special
discounts for things such as bus tickets, cultural events and movies, special shopping days, and telephone
reassurance (lifeline) services.

Medicare and Medicaid and/or Supplemental Security Income are indispensable resources for older adults
who require home health, in- or outpatient physical or occupational therapy, or nursing home services:

Medicare, the U.S. national social insurance health care program for everyone older than 65, includes
coverage for hospital stays (extended hospital care), home health services, hospice care, and voluntary
medical insurance (e.g., doctor’s fees, outpatient services). Medicare also covers people with end-stage
renal disease. Medicare Part D, a relatively recent benefit, pays for part of prescription drug costs.
Funding for Medicare comes from Social Security contributions, monthly premiums from participants,
and general federal revenues (Barker, 2014, p. 264).
Medicaid, a health care program created in 1965, pays for medical and hospital services for people who
cannot afford them. Eligibility is based on income level and inability to pay for health care insurance.
Funding comes from federal, state, and sometimes county governments. In most areas, Medicaid is
administered via local public assistance offices.
Supplemental Security Income (SSI) recipients may also receive other services in their local Social
Security offices, such as help applying for Medicaid (Barker, 2014, pp. 263–264). SSI is designed to
provide income to those who have few financial resources and are also blind, disabled, or aged. SSI
provides cash to meet basic needs for food, clothing, and shelter.

Social workers often help clients understand how to apply for and use these programs properly and effectively.
Clients in both rural and urban areas often require additional information about where to go and how to apply
for SSI.

470

Culturally Competent Care of Older Adults

Gerontological social workers must consider the language, customs, history, and preferences of racial and
ethnic groupings of older adults. Cultural values of respect for elders’ wisdom and accomplishments, and
obligations to care for extended family members, require humble consideration, as do holidays, special
celebrations, and level of Americanization.

The number of older adults who belong to ethnic and cultural minorities is growing faster than the average for
the United States as a whole. People of color may have increased needs for social services because they are
especially vulnerable to poverty and experience continued discrimination. Some of these older adults also
experience abuse.

471

Issues of Aging and Old Age

Why are some older adults quite active and vital at age 90 while others are frail at age 60? What causes aging,
and why is there so much variation in aging among human beings compared with other species? How come
some older adults perform as well as younger people on cognitive tasks while others show significant deficits
in cognitive functioning? Is “keeping active” the secret to avoiding memory loss? How come some social
contexts and societies provide significant care for their elders while others leave it to the individual and his or
her resources? And why is there so much variation in public policy about aging? These are some of the issues
that confront anyone working to help older adults cope with aging (Manfredi, 2009).

472

Biological and Physiological Aspects of Aging

All humans age, and after 30, there is a gradual decline in all organ systems (Hooyman & Kiyak, 2010). All
perceptual and sensory systems, as well as coordination, speed, speed of response, and strength, also decline
with aging. However, within individual people, biological change rates vary for different physiological
systems, organs, tissues, and cells. Furthermore, practically every aspect of aging and development for adults is
determined by the interplay among hereditary and age-related biological process and the environmental or
cultural influences. A healthy lifestyle, good diet and exercise, good health care, and self-management of
chronic stress are known to increase longevity and life span.

A great deal of anxiety surrounds the four Ds of aging—death, dementia, depression, and disability. Everyone
will experience death, but the others are not inevitable. It is realistic to assume, however, that about 80% of
older adults will likely have at least one chronic condition that may or may not interfere with their ADLs,
such as arthritis or high blood pressure. Geriatric studies estimate that between 25% and 50% of older adults
living in the community suffer from chronic pain that affects their daily functioning (Park & Hughes, 2012).
Examples of pain-related disorders are osteoarthritis, osteoporosis, neuropathic conditions (nerve-related
diseases), and degenerative spine conditions (Cavalieri, 2005; Park, Hirz, Manotas, & Hooyman, 2013).
Other broad categories of physiological issues commonly found in the geriatric population include vision
impairment, incontinence, depression, hearing loss, balance and mobility issues, and memory disorders.
Today, many options exist to enhance fitness and maintain a person’s ability to remain active and independent
into old age. Exercises such as yoga, Pilates, and tai chi can be wonderful options to help older adults stay fit
and strong.

Improvements in assistive technology also help. Some examples of the new technologies are voice-activated
devices (e.g., wheelchairs), mobile applications, home telecare (a more sophisticated version of medical alert
systems), and specially designed tools for performing tasks that have become difficult for older adults, such as
picking up things from the floor.

473

Cognitive and Psychological Aspects of Aging

Psychologically, aging people experience changing sensory and cognitive processes. For example, perception,
motor skills, problem-solving ability, and drives and emotions often change as people age. Also, age-related
slowing in processing speed greatly affects cognitive functions, such as the speed of encoding and retrieving
information, selective attention, integrating information, and switching between multiple tasks. Cultural
factors and personal factors such as age stereotypes and self-esteem exert huge effects on memory and the
allocation of attention.

Fortunately, age-related differences in cognitive performance are minimal when older adults can draw on
previous knowledge or experience. Memory performance can improve when older adults are taught ways to
remember information, such as making word lists or shopping lists. Brain gyms, learning how to play an
instrument, or doing word or Sudoku puzzles, as well as participation in therapeutic arts (e.g., music,
sculpture, drawing) also facilitate brain health.

The five-factor model (Big Five), a trait approach, has been extremely influential in describing personality
across the adult’s life span. The five traits are neuroticism, extraversion, openness to experience, agreeableness,
and conscientiousness. This model is used because personality traits predict mortality; for example, people
who score high on conscientiousness are at lower mortality risk across the entire life span. Conscientious
people are more likely to manage their lifestyles for greater health and to maintain healthy relationships
(Friedman & Martin, 2012). They end up in happier marriages, better friendships, and healthier work
situations, which create healthy, lifelong pathways for them.

In addition, realistic pessimism may be better for one’s health than unrealistic optimism (Friedman & Martin,
2012). Unrealistic optimism can lead to underestimation of risk—for example, health hazards. Negative
emotions and unrealistic optimism are both associated with higher levels of stress and more intense reactions
to stressors.

Social Work in Action

474

Alysia and Rachel Educate Staff and Older Clients About Sitting
Disease
Two gerontological social workers at the Seashore Garden Living Center (SGLC), Alysia and Rachel, read a study published in the
Journal of Physical Activity and Health that revealed how sitting too much may increase the risk of disability in people over age 60.
Specifically, the research has linked too much sitting to increased risk of heart failure, Type 2 diabetes, and death from cancer, heart
disease, or stroke. Sitting too much may also affect mood and creativity (Hellmich, 2012a, 2012b).

Health problems related to sitting disease are increasing universally, and the SGLC social workers have observed this phenomenon
among the residents they serve. Alysia and Rachel have introduced this research at multidisciplinary team meetings. Through
education and counseling, the staff members at SGLC intend to heighten their residents’ awareness of the importance of remaining
physically active.

1. How can the social workers collaborate with other SGLC staff to ensure that sitting disease is avoided in their facility?
2. What creative solutions, from community supports and connections, could be devised to encourage residents to remain

active?

Time to Think 11.3

Do you have habits and traits that will help maintain good cognitive and psychological functioning as you age? Do you stretch your
mind from time to time? Are you conscientious? Are you a realistic pessimist?

Neurocognitive Disorders (Dementias)

There is a great deal of confusion, as well as anxiety, about dementia. Social workers help family members
understand that dementia is not a specific disease. Essentially, dementia refers to a group of symptoms that
affect social and thinking abilities so severely that everyday functioning is affected. Dementias are classified as
mild, moderate, or severe neurocognitive disorders. Some causes of dementia are treatable and even reversible.

Families need to know that memory loss usually occurs in dementia, but this alone does not mean someone
has dementia. According to the Mayo Clinic, dementia is diagnosed when the following two types of
neurocognitive deficits both occur:

Problems with at least two brain functions—for example, memory loss and impaired judgment or
language
Inability to perform some ADLs, such as paying bills or driving without getting lost

Alzheimer’s disease is the most common cause of a progressively degenerative dementia, accounting for
between 60% and 80% of all dementia cases (Burock & Naqvi, 2014). The second most common type of
dementia, which is caused by stroke and not Alzheimer’s disease, is vascular dementia.

Many people are nervous that President Trump will renege on his promises to not cut federal entitlement
programs such as Medicare and Social Security. Generations articles by Alicia Munnell and John Rother
provide strategic solutions to potential aging issues. Munnell’s article, “Restoring Public Confidence in
Retirement Income,” devises a 5-point plan on steps the Trump administration could take to secure America’s

475

retirement income system. The points include the following: (1) maintaining Social Security, (2) making
401(k)s fully automatic, (3) covering the 50% of current private-sector workers who have no retirement plan,
(4) encouraging people to use their homes as equity for retirement income, and (5) encouraging longer
working lives (http://www.lgbtelderinitiative.org/newsevents/american-society-on-aging-publishes-journal-
on-aging-policy-for-the-new-white-house-administration/).

Active aging is becoming older but continuing to grow and participate in family, community, and society.

Source: iStock Photo / kali9

Current Trends

476

Assistive Technologies for Aging in Place
“60 Minutes” ran a segment in 2014 on the fascinating Lift Labs sensor spoon. It was created by an engineer who wanted to help
improve the quality of life of older adults who experience hand tremors, such as from Parkinson’s disease. The International
Essential Tremor Foundation (n.d.) website features the spoon, which has sensors in the handle that detect a hand tremor and
quickly respond to cancel the tremor and steady the spoon. The spoon helps a person focus less on how he or she is eating and more
on the people he or she is eating with.

In addition, the site features technology such as the SpillNot mug for beverages; the Soap Safety Sack, which keeps soap from
slipping out of people’s hands and causing accidents; the MagnaReady clothing line, which features dress shirts with magnetically
infused buttons that help people with limited motor skills dress independently; and multiple iPad apps to help with typing and so
much more.

1. How helpful might assistive technology and novel devices be to maximize good nutrition and minimize the need for extra
staff in a long-term care setting?

2. How might assistive technology and novel devices be used for older people who live at home or are alone?

Spotlight On Advocacy

477

MoMA Alzheimer’s Project
In 2009, the Department of Education in the New York Museum of Modern Art (MoMA) published Meet Me: Making Art
Accessible to People With Dementia, a comprehensive resource for creating art programs for individuals with Alzheimer’s disease and
their caregivers. The museum decided to use the resource to create a project of its own, called Meet Me at MoMA, which is an
outreach program encouraging this population to visit and helping them enjoy the museum’s art.

It was such a success that the museum created the MoMA Alzheimer’s Project, a nationwide expansion of Meet Me at MoMA and
the museum’s other art and dementia programs. It was funded by a major grant from the MetLife Foundation. For the project,
museum staff, along with Alzheimer’s specialists, have developed resources that can be used by museums, assisted-living facilities,
and other community organizations serving people with dementia and their caregivers.

At the easy-to-use website (www.moma.org/meetme/index), you can read interviews with experts in the field of art, aging, and
Alzheimer’s disease; learn about the findings from an evidence-based research study conducted by New York University School of
Medicine to evaluate the efficacy of the Meet Me at MoMA program; review guides for creating arts-related programs in various
settings; and explore works from MoMA’s collection through thematic art modules or by browsing the artwork section. In addition,
this site includes special multimedia content pertaining to the museum’s overall programming in art and dementia.

1. How can social workers draw more from the arts to help clients who experience various forms of dementia or neurocognitive
disorders/challenges?

2. In what types of policy advocacy might social workers engage to reproduce projects such as this in other communities?

The Alzheimer’s Foundation of America (AFA) is profoundly concerned about the deep cuts proposed in
President Trump’s federal budget for fiscal year 2018. Some believe this budget marks a significant step
backward in our quest to find a cure for Alzheimer’s and will sharply curtail access to quality long-term care
services and supports (Alzheimer’s Foundation of America, 2013).

In 2011, President Obama had signed the National Alzheimer’s Project Act into law, making Alzheimer’s
disease a medical priority for the United States. Obama’s plan aimed to encourage research to improve
prevention and treatment by enhancing quality and efficiency of Alzheimer’s care, expanding supports for
people with Alzheimer’s disease and their families, and enhancing public awareness and engagement.
Alzheimer’s disease appears repeatedly in the news as a public health problem, because the disease is
burdening a growing number of U.S. older adults and their families (Stix, 2012).

Depression, Mental Health, and Other Emotional Problems

Aging is not always accompanied by worsening mental health; however, it may occur. Depression and anxiety
are especially problematic because they affect a person’s ability to make good choices and participate in health-
promoting behaviors. But when dealing with older adults, it is important to keep in mind that depression is
not a normal part of aging.

Depression is widely underrecognized and undertreated. One reason for such underrecognition is that families
rarely realize that people who are experiencing other major illnesses, such as cancer, diabetes, heart disease,
Parkinson’s disease, and stroke, are frequently depressed as well.

Clearly, depression and social relationships are intertwined. The experience of grief, interpersonal strife, or

478

role transitions, which are common as people age, may indeed influence mood. The other side of the coin is
that older adults who receive a diagnosis of depression then experience stigma because of reactions from other
people and themselves.

Whether the older adult’s problem is depression or something else, gerontological social workers work with
family members as well as the older adult. Their client could be a middle-aged and overwhelmed caregiver of a
97-year-old widow or adult children feeling anxiety and guilt because they do not know how to help their 80-
year-old dad who is a veteran diagnosed with diabetes and dementia.

Substance Use/Addictions

Unfortunately, when major depression occurs, some older adults resort to use of alcohol or other substances.
Detecting alcohol or drug problems in older adults is challenging. Because of ageism, family members and
clinicians are reluctant to ask about it or do not think to assess for addiction. When a substance use problem is
detected, doctors may fail to realize that even modest amounts of alcohol or drugs can be problematic. Older
patients have a significantly reduced ability to metabolize these substances, as well as increased brain
sensitivity to them. And, the cognitive challenges common with advancing age make self-reporting—as well
as self-monitoring—unreliable.

Alzheimer’s disease is a growing public health problem in the United States.

Source: iStock Photo / monkeybusinessimages

Even small amounts of drug and alcohol use can have serious consequences for older adults. For some who
have never used substances or consumed alcohol, substance use may start when they begin to experience losses
or unwanted transitions. Also, prescription medication use or misuse may be associated with falls in older
populations, and substance-misusing older adults may be at higher risk for different cancers and organ damage
(Schulte & Hser, 2014).

A particular problem is a growing epidemic of alcohol and drug use and mental illness among the 78 million
retiring, aging boomers that have wealth, health, and education (Friedman, 2013). Boomers came of age in
the 1960s and 1970s, when illicit drug experimentation with cocaine, opiates, and marijuana was pervasive.
Therefore, younger social workers should consider the contextual realities in which baby boomers have grown
older and maybe not always wiser.

Although alcohol is the most commonly misused drug among older adults, nonmedical use of prescription
drugs is a rapidly growing problem. Some studies estimate that nearly 10% of older adults misuse prescription

479

drugs, with serious abuse potential—most often antianxiety benzodiazepines such as Klonopin, sleeping pills
such as Ambien, and opiate painkillers such as oxycodone. When it comes to nonmedical use of prescription
medication, women far outnumber men.

Sexual Activity

Many older adults still want and need to be intimate with others, and want to have an active and satisfying sex
life. But physical or emotional problems may thwart their desires. Both men and women experience normal
physical changes as they age that affect their ability to have and enjoy sex. For example, an older woman’s
vagina may become shorter, narrower, thinner, stiffer, and drier, all of which affect function and pleasure. As
men age, impotence or erectile dysfunction becomes more common. With erectile dysfunction, a man loses
his ability to get and keep an erection for sexual intercourse, or it may take longer for another erection to
become possible.

Sexual problems may also be due to illnesses, disabilities, medicines, or surgeries. The main physical problems
that affect sexual relations include arthritis, chronic pain, dementia, diabetes, heart disease, incontinence,
stroke, depression, surgery (e.g., hysterectomy, mastectomy, prostatectomy), medications, and alcohol.

Older adults can also contract sexually transmitted disease (e.g., syphilis, gonorrhea, chlamydial infection,
genital herpes, hepatitis B, genital warts, and trichomoniasis). Almost anyone who is sexually active is also at
risk of being infected with HIV, the virus that causes AIDS. The number of older adults with HIV/AIDS is
growing (Stine, 2014).

Emotions also play a role in sexuality. How you feel affects what you can do. Many older couples find greater
satisfaction in their sex life than they did when they were younger, because they have fewer distractions, more
time and privacy, no concerns about pregnancy, and more intimacy with their lifelong partner. However, older
women may be unhappy because their looks have changed and they feel less attractive. Older men may fear
that erectile dysfunction will become even more common as they age, and stress can trigger it. Older couples
face daily stresses like everybody else, in addition to having concerns about age, illness, retirement, and other
lifestyle changes.

Relationship problems can affect a couple’s ability to enjoy sex as well. Marriages differ substantially in their
starting levels of marital quality, and multiple contextual factors can accelerate or delay the rates of change for
certain marriages. For example, the presence and age of children in the home, work demands, and family
support or interference affect the experience and quality of marriage over time. Intimacy—mutual sharing of
personal feelings, honesty, and respect—becomes increasingly important as relationships develop and mature.
Enjoying time with friends and relating to each other with acceptance and respect both enhance the intimacy
between a couple (Blieszner, 2014; Qualls, 2014; Syme, 2014).

Social workers must adopt the attitude that sexuality in older adults should not be stigmatized or considered
taboo. If partners are available, the potential for passion exists. Passion, caring, and intimacy are enduring
socioemotional needs for adults of all ages. Sexuality is equally important to single, partnered, widowed,

480

married, and LGBQT (lesbian, gay, bisexual, questioning, and transgender) couples.

Current Trends

481

Senior Sex—and the Disease That Comes With It
Ezekiel Emanuel (2014), an oncologist at the University of Pennsylvania and contributing opinion writer for The New York Times,
wrote a titillating column headlined “Sex and the Single Senior.” Emanuel’s Sunday op-ed piece cited four factors contributing to an
increase in sexually transmitted infections among older Americans:

Retirement communities and assisted-living facilities have lots of similarly aged people living in close proximity to one
another.
Older people are living longer and healthier lives, and remaining sexually active much later into life (e.g., the National Survey
of Sexual Health and Behavior has reported that among people over age 60, more than half of men and 40% of women are
sexually active).
Older adults grew up before the safe-sex era and don’t tend to think they should use condoms.
Older men who use Viagra and similar drugs are 6 times less likely to use condoms than are men in their 20s (according to a
study published in the Annals of Internal Medicine).

Social workers must be aware of these trends and assess older adult clients for sexually transmitted diseases. Also, a public health
campaign on safe sex aimed at older adults living independently is needed.

1. Should the AARP cajole its members to be sexually responsible? Should Social Security include some information on
sexually transmitted diseases and proper condom use when it sends out checks?

2. What are some other ways to effectively prevent sexually transmitted diseases among older persons?

Loneliness

Some aspects of aging, such as blindness and loss of hearing, place people at special risk for becoming isolated
and lonely. People also become lonely as mobility decreases and friends pass away.

According to leading experts, feeling extremely lonely can increase an older adult’s chances of premature death
by 14% (Harms, 2014). Compare this statistic with the finding that disadvantaged socioeconomic status
increases by 19% the chances of dying early. Loneliness is a risk factor for such physiological responses as high
blood pressure, insulin resistance, obesity, inflammation, and diminished immunity (Harms, 2014).

Two types of loneliness have been noted: emotional isolation (loose emotional attachment) and social isolation
(loose social ties). Both kinds of loneliness affect well-being and physical health across time (Weiss, 1973).
What is important for social workers to discern is that being alone differs from being lonely. There are many
older adults who actually crave solitude, and for them aloneness can be a healing power. For others, however,
loneliness can hurt. These variations in loneliness actually seem to have a genetic component (Boomsma,
Cacioppo, Muthén, Asparouhov, & Clark, 2007). Thus, it is not solitude or physical isolation itself but,
rather, the subjective sense of isolation that is profoundly disruptive (Harms, 2014). In other words, older
people living alone are not necessarily lonely if they remain socially engaged and enjoy the company of those
around them.

Suicide

Late-life suicide is concerning and requires more attention from health care providers, researchers,
policymakers, and society at large (Joiner, 2005; Manetta & Cox, 2013). Of all age/gender/race groups, white

482

men over the age of 85 are at the greatest risk of completing suicide. Comparatively, the rate of suicide for
women tends to decline after age 60 (after peaking in middle adulthood, ages 45–49; American Association of
Suicidology, 2012).

Although older adults attempt suicide less often than people of other age groups, they have a higher
completion rate. Firearms are the most common means used for completing suicide among older adults, with
men using firearms far more often than women (Callanan & Davis, 2012; Lester, Haines, & Williams, 2012).

A leading cause of suicide among older adults is untreated depression. Gerontological social workers need to
ask relevant assessment questions to determine their clients’ suicide risks. Common risk factors include the
recent death of a loved one; physical illness, uncontrollable pain, or the fear of a prolonged illness; perceived
poor health; major changes in social roles (e.g., retirement); and social isolation and loneliness.

483

Social Aspects of Aging

The human need for connectedness is tangible, and social workers must be ready to assess the following key
dimensions that sustain healthy relationships (Wilmoth, Adams-Price, Turner, Blaney, & Downey, 2014):

Intimate connectedness (from someone who affirms you)
Relational connectedness (from face-to-face contacts that are mutually rewarding)
Collective connectedness (from feeling that you are part of a group or collective beyond individual
existence)

All these forms of connectedness help older adults cope with the changing roles and definitions of self that
society places on them. For example, the role expectations and status of grandparents differ from those of
parents, and the roles of the retired are remarkably different from those of people who are employed.

Ageism

Negative stereotypes hurt older people and may shorten their life span. A longitudinal study of 600 people
over age 50 found that those with more positive self-perceptions of aging lived 7.5 years longer than those
with negative self-perceptions of aging (Levy, Slade, Kunkel, & Kasl, 2002). The study also found that older
adults exposed to positive stereotypes have significantly better memory and balance, whereas negative self-
perceptions contribute to worse memory and feelings of worthlessness. Negative perceptions of aging are
difficult to combat, however. Age stereotypes are often internalized at a young age—long before they are even
relevant to people. By age 4, children appear to be familiar with age stereotypes that are then reinforced over
their lifetimes (Levy, 2003).

Most older adults are acutely aware of the negative stereotypes. Doris Roberts, the actress who played
Raymond’s mother on the hit television show “Everybody Loves Raymond,” testified in 2002 at a Senate
hearing before the Special Committee on Aging about the effects of age stereotypes. This Emmy-award–
winning actress in her 70s said that she and her peers are all too often portrayed as dependent, helpless,
unproductive, and demanding rather than deserving. She further noted, “In reality, the majority of seniors are
self-sufficient, middle-class consumers with more assets than most young people, and the time and talent to
offer society” (Dittman, 2003, p. 50).

Social workers must dispel myths about aging, be aware of the extreme emphasis on youth and the
discrimination against elders in the United States, and advocate for respect, equality, and visibility. The value
that the media and society place on youth seems to explain why cosmetic products and surgeries have
increased.

Time to Think 11.4

Do you consider yourself to be ageist? What stereotypes about aging do you have? What have you learned in this chapter about older
adults that might help dispel those stereotypes?

Think of an older adult you know. In what ways are the stereotypes invalid for this person?

484

Aging in Place

Aging in place is the ability to live in one’s own home and community safely, independently, and comfortably,
regardless of age, income, or ability level (Wiles, Leibing, Guberman, Reeve, & Allen, 2014). The idea is
growing in popularity, although housing and health care programs and policies require alteration to support
this level of independence, such as rethinking housing design, developing better assistive technology, and
revising health care delivery practices.

Aging in place is also a movement that supports the notion that older people should be permitted to stay in
their own homes rather than forced to go to an assisted-living facility or nursing home. The movement was
created to help American communities prepare for the aging population. Multiple agencies and organizations,
including the National Association of Area Agencies on Aging, support this movement. One concept the
aging in place movement supports is naturally occurring retirement communities, which are buildings or
neighborhoods that were not originally built to serve older adults but over time have attracted a large
proportion of older residents who intend to age in place. Nine laboratory communities have also been
established by the movement. Elders Village is a similar network. In addition, a wide variety of websites and
organizations have sprung up across the United States to help people remain in their own homes for as long as
possible.

The term aging in place is used widely in aging policy and research but is rather underexplored with older
people themselves. Gerontological social workers realize how much older people desire choices about where
and how they live as they age and are prepared to provide information about options. They know that aging in
place supports independence, autonomy, and the maintenance of caring relationships and familiar roles for
aging adults.

Caregiving

Caregiving is an act of love, a necessity, and priceless. American families provide 80% to 90% of all in-home
long-term care services for their aging family members and other loved ones. These services often include help
with ADLs, medical services coordination and supervision, administration of medications, and help with
emotional, financial, legal, and spiritual concerns. One researcher defines caregiving as care work (Meyer,
2000) and notes the immense load carried by American women. If caregiving services were provided by
America’s national health care system, the estimated costs would be about $250 billion per year.

The Sandwich Generation is a buzz term coined to describe caregivers who find themselves squeezed in
between caring for their children and their elder parents or other older adult family members. While the
Sandwich Generation is not a new form of family caregiving, these caregivers are getting lots of research
attention. Currently, the typical American Sandwich Generation caregiver is in her mid-40s, employed, and
married, and she cares for her family and older parent(s) (Cravey & Mitra, 2011; Smith-Osborne &
Felderhoff, 2014). Increasingly more men are finding themselves in a caregiving role, too.

An ever-growing portion of family and Sandwich Generation caregivers reside in rural communities, where

485

they find themselves with geographic barriers to resources and isolation from other caregivers, family
members, or informal supports. Lack of service availability, lack of care networks, and isolation from other
caregivers and family members add to rural caregiver stress, burnout, and depression.

Caregiving is not the same for all cultures, and social workers must understand this reality. Unique traditions,
values, and rituals exist within cultures and populations, and the diversity among older adults and within
subtypes of the population is often ignored. Increasing numbers of people of color are aging, and each
population group may have its own set of family values, help-seeking behaviors, access to resources and
services, and so on. Other special populations include people who live in rural areas and those who have
developmental disabilities.

Long-Term Care

Wishing to avoid placing the burden of caregiving on others, or not having other family members to depend
on in old age, some people secure long-term care insurance, a type of policy that covers basic daily needs over
an extended time and helps people cope with the cost of chronic illnesses, such as Alzheimer’s disease and a
number of physical and mental challenges.

The policies typically cover out-of-pocket expenses for assistance with everything from the basics—bathing
and dressing—to skilled care from therapists and nurses for months or even years. Long-term care insurance
typically covers home care, assisted living, and nursing homes. These are costly services. For example, 1 hour
of care from a home health aide can cost about $20, while the average private nursing home room for someone
with dementia costs $87,000 a year or $7,500 a month (Geewax, 2012). Neither routine employer-based
medical insurance nor Medicare will pay for extended periods of custodial care.

Most long-term care policies have a waiting period that works like a deductible. So if a home nursing aide is
needed, you may have to wait 90 to 120 days before your benefits start to cover those costs. Only a fortunate
few will have long-term care insurance; out of more than 313 million Americans, only about 8 million have
any such protection (Zamora, Nodar, & Ogletree, 2013). The low participation rate largely reflects the high
cost of long-term care insurance, which averages about $400 per month.

A fortunate few will have long-term care insurance, but even that option is looking sketchy as more
companies exit the business. Insurance giants such as Prudential and MetLife have recently pulled back from
offering long-term care policies. Companies such as John Hancock and Genworth Financial have turned to
state regulators, seeking permission to hike premiums dramatically. Depending on the location, insurers have
requested rate increases of 18% or 40%, or in a few cases even 90% (Geewax, 2012).

The 78 million baby boomers now entering retirement are likely to suffer from the lack of long-term care
insurance. Many of them have been hurt deeply by the Great Recession, losing good jobs and being “too old”
or too discouraged to find new ones, and losing nearly half the value of their retirement funds with little time
to earn it back. Many in this generation do not have children to care for them in old age. Few have long-term
care insurance; so they are expected to fall so far into poverty trying to provide themselves with paid care that

486

they will qualify for Medicaid, the medical care program for the deeply impoverished.

Current Trends

487

The Village Concept
Originating in Beacon Hill in Boston more than a decade ago, the village concept for aging in place has since spread rapidly
throughout the United States. Each village is independent and diverse, and each works a little differently depending on the layout
and makeup of the community or village it is serving. However, they all share the common goal of providing a way for older adults to
age in place with dignity.

The basic structure works like this: Members of the village pay a monthly or annual fee into a fund that will help them obtain
services when needed. Transportation and home maintenance are at the top of the list for most members. Providers, which include
individuals and businesses, have been vetted and approved by the organization. These providers offer the same range of services
found in assisted-living places in a cost-effective manner, but village members remain at home (Accius, 2010).

The financial benefits are great. For example, in New Hampshire the cost of assisted living is $3,000 or more per month. By
contrast, the annual yearly membership fee to belong to one of the village networks in New Hampshire is between $300 and $600
(Doherty, 2013).

1. How might social workers be involved in the village movement in rural and urban areas?
2. What would be important considerations in implementing the village concept in your neighborhood?

Elder Abuse

Sometimes the stress and demands of caregiving are so overwhelming to family and other caregivers that elder
abuse, or maltreatment of an older person, occurs. Physical or mental ailments may cause older adults to be
more trying companions than usual for loved ones living with them.

Older adults may be victimized by non-caregivers as well. As older adults become more physically frail, they
are less likely to stand up to bullying or fight back if attacked. They may not hear, see, or think as well as they
used to, allowing space for unscrupulous people to take advantage of them. In addition, their retirement funds
and benefit checks, unmortgaged homes, and belongings collected over a lifetime make them tempting
targets.

Only recently have the nature and extent of victimization been recognized as a problem. Unfortunately, older
adults across America are being abused and harmed in some major ways. More than half a million occurrences
of abuse against older Americans are reported yearly, and millions more go unreported. Those who are most
likely to be victimized are unemployed, traumatized by a prior event, getting by with a low household income
(less than $35,000 per year), social services clients, in need of assistance with ADLs, or in poor health.

Elder abuse takes many forms:

Physical abuse: Non-accidental use of force against an older person that results in physical pain, injury,
or impairment; includes hitting, shoving, and inappropriate use of drugs, restraints, and confinement.
Serious violence in the form of murder, rape, robbery, aggravated assault, and kidnapping also occurs
with older adults. Although most of those who physically maltreat older adults are family members,
acquaintances account for 19% of physical maltreatment and strangers for 3%.
Emotional or psychological abuse: Speaking to or treating older persons in ways that cause them

488

emotional pain or distress. Verbal forms include intimidation through yelling or threat, humiliation and
ridicule, and habitual blaming or scapegoating. Nonverbal abuse is ignoring the older person, isolating
the person from friends or activities, or terrorizing or menacing the person. Emotional or psychological
abuse is a challenge to detect, and what social workers observe may reflect a lifelong history of harsh-
sounding communication. This may take the form of infantilizing or willfully isolating an older adult

family member (McInnis-Dittrich, 2014).
Sexual abuse: Intimate contact with an older person without the person’s consent. Sexual abuse includes
physical sex acts and also forcing the person to watch pornographic material or watch sex acts.
Neglect (and abandonment): Caregivers’ failure to fulfill a caretaking obligation. Neglect or
abandonment constitutes more than half of all reported cases of elder abuse. It can be active
(intentional) or passive (unintentional, based on factors such as ignorance or denial that an older person
needs as much care as she or he does).
Financial abuse (and exploitation): Unauthorized use of an older adult’s funds or property, either by a
caregiver or an outside scam artist. Financial exploitation is especially problematic. Non-caregivers may
victimize older adults in the form of fraud through investments; charity contributions; car and home
repairs; sweepstakes and prizes; home mortgages; health, funeral, or life insurance; health remedies;
lottery scams; or telemarketing. Older adults are vulnerable because they often have medical needs,
diminished capacity, and a pool of financial resources to exploit.

Exhibit 11.7 breaks down the perpetrators of physical and emotional abuse. The clear majority is family and
friends, but acquaintances and strangers also account for a fair number of the perpetrators.

489

Spiritual Aspects of Aging

Much variability exists as to the definitions of spirituality and religion. Spirituality equates to a person’s
individually experienced connection to a higher being and a “felt” experience of connectedness and
transcendence. Religion is organized spiritual practice that tends to focus on the link between a higher power
and human existence, whereas spirituality is more about where and how one finds meaning in life.

Living in and for the moment, asserting oneself against loss and fate, and transcending the previous limits of
self in society are spiritual dimensions and opportunities older adults face. “Meaning and spirituality are the
drugs of age, the consolation prizes” (Thomas & Eisenhandler, 1999, p. 211). In other words, people
generally seek meaning and a renewed spirit as they move deeper into old age.

Benefits of Spirituality and Religion in Old Age

Gerontologists now recognize that religion and spirituality are part of older people’s physical and mental
health (Carr & Sharp, 2014). They appear to be related to enhanced feelings of well-being, inner emotional
peace, and satisfaction with life—which all help maintain health and overcome illness. In addition, the
opportunity to help others in times of need has been noted as a part of the reason religious participation and
spirituality have a positive influence on health.

Exhibit 11.7 Breakdown of Confirmed Perpetrators of Elder Abuse

Source: UNC School of Medicine Division of Geriatrics. Used with permission.

Affiliation with religious institutions also tends to promote connectedness and decrease isolation. Many

490

centenarians identify regular participation in formal religious services as important. Older adults who regularly
attend religious services show improved health status, reduced incidence of chronic disease, and more effective
coping with stress (Hoeger & Hoeger, 1995). Spiritual beliefs and practices are a part of culture that often
help older adults manage life challenges (Ellor, 2013; Mukherjee, 2016).

Illness, Death, and Faith

Spirituality is the most frequently addressed topic of hospice visits with the terminally ill, with death anxiety a
distant second (Reese & Brown, 1997). Hospice social workers often note that the greatest fear people express
related to death is that they will lose control over the circumstances of their dying and be forced to endure
pain, suffering, and indignities they did not choose. Many people fear this more than they fear death itself
(Atchley, 2009, p. 140).

Americans’ discomfort with aging and dying is often unveiled in debates about governmental policies. For
example, New Jersey’s assisted suicide bill underwent a contentious and controversial debate. Those in
opposition to the bill were concerned about the spiritual dimensions but focused their talking points on the
practicalities: It allowed poisonous drugs to be used without requiring an independent, disinterested witness to
be present. Those who favored the bill believed it would allow people to die with dignity.

491

Policies Affecting Older Adults

Before government began to address older adults’ needs, family members were responsible for their aging
relatives. Amid agrarian life, older adults helped their families by doing farm chores. People without family
depended on faith-based organizations or the almshouse. Older adults living in the 21st century receive
support from family in exchange for serving as babysitters to grandchildren and as house sitters. However,
government-provided resources are still greatly needed for the aged poor to survive and thrive.

Pensions. The U.S. government offers pension plans to older adults who exhibit a good work history.
The best known of these is Social Security. The Social Security Act of 1935 served to enact a nearly
universal pension plan for older Americans who paid into the Social Security system. Widows and their
children were included in a 1939 expansion of this legislation. Subsequently, other categories were
included, such as domestic and farmworkers, government workers, military veterans, religious personnel,
and self-employed people (Huttman, 1985).
Health insurance and Medicare. Older people had to pay for their own health care until the Medicare
legislation was enacted as part of the Social Security Act of 1965. For a very low monthly fee, Medicare
Part A covers hospitalization and some follow-up care. Medicare Part B pays for outpatient hospital
care and some doctor’s services (older adults must pay an additional premium to get Part B coverage).
Medicare C only partly covers around 100 days for nursing home care and blood draws. The relatively
new Medicare Part D provides for prescription drug coverage.
Area Agencies on Aging. In 1965 the very important federal-level Older Americans Act was enacted. Its
mission was to keep older adults living independently for as long as possible by providing information
on services that are available to them. To do so, it authorized state units and local Area Agencies on
Aging. Amendments to the Older Americans Act, approved in 1981, allowed for information and
referral services for non-English-speaking older adults; provided legal services and transportation; and
offered in-home assistance in the form of health aides, homemakers, and visiting and telephone
reassurance activities.

Time to Think 11.5

What if the Social Security program stopped and you had to invest individually for your own retirement? Do you think you would do
so with adequate investments to make sure you had a secure retirement income?

492

Diversity and Aging

The experience of aging in America differs for people across different cohorts, social classes, races and
ethnicities, abilities, religious and spiritual beliefs, and genders. Educational and economic factors also affect
attitudes about health, health literacy, and exposure to health information.

Gerontological social workers realize that health and mental concerns increase with age, as older adults cope
with the loss of their spouses or partners and their friends. In addition, some older adults also experience
emotional, verbal and physical abuse. No matter the social worker’s or client’s age or race/ethnicity, respect
and trust are crucial wherever older clients are aging and wherever the social worker is working (Joo, Wittink,
& Dahlberg, 2011).

493

Age

Age is a multidimensional concept that comprises multiple meanings:

Chronological age (the number of years that have elapsed since birth)
Biological age (an estimate of one’s potential life span—measures a person’s vitality or neurobiological
health level)
Psychological age (one’s adaptive capacities related to learning, memory, intelligence, emotional control,
motivational strengths, coping styles)
Social age (social roles and expectations people hold for themselves and others, such as “mother” and the
behavior that accompanies that role)

Ageism and negative stereotypes are serious problems that affect older adults globally. People may have overly
positive views of aging (idealizing old age), or they may have overly negative views of aging and older adults
(viewing elders as useless and inadequate). Labels of age cohorts also stereotype people. For example, an older
adult male may be from the “Greatest Generation” or a “baby boomer.” One label makes the man seem noble
and competent, while the other makes him seem whiny and arrogant.

Time to Think 11.6

What stereotypes do you have about people from different generations? Which are most positive and which more negative?

Do you feel that the label for your generation is positive or negative? How accurately does it reflect your self-identity?

494

Class

During their lives, older adults are usually assigned to social classes on the basis of their occupations, which
vary in pay structure, prestige, and the power to influence others. Once they retire, they are stereotyped on the
basis of their economic resources and living conditions. Thus, a person who may have been considered solidly
middle class during youth and middle adulthood may come to be seen as lower class if for some reason he or
she is reduced to living in smaller, less-prestigious quarters in old age.

The U.S. Census Bureau reveals the percentage of elders who have incomes just above the poverty line. About
40% of Americans aged 60 to 90 have experienced at least 1 year of living near or below the poverty line. The
percentage sharply increases for unmarried blacks with less than a high school education (Hoyer & Roodin,
2009, p. 44).

The inequities of class also extend to those who care for older adults. Lower-class and relatively uneducated
certified nursing assistants provide hard labor and the lion’s share of physical and direct care in nursing home
settings; yet these workers get much less pay than does the social worker or nurse caring for the same
residents.

495

Ethnicity and Race

Older adults come from all ethnic and racial backgrounds. However, by 2050, the percentage of people of
color over age 65 in the United States is projected to increase; their rate of growth is faster than that of the
white population.

Ethnicity and race are a factor in longevity as well. The average life span of an African American man is less
than that of a white man, and African American women are the most likely racial group to become widowed.
Asian and Latino older adults appear to have longer life expectancies than do whites; however, predictions
indicate that this rate may change as the poor-nutrition and low-exercise American lifestyle takes hold among
immigrants of these ethnicities.

There is a paucity of information about race and ethnicity in the area of caregiving. However, there is a
discernible lack of diversity within caregiving programs, perhaps because many people from ethnic and racial
minorities are reluctant to seek services, existing programs and supports erect cultural and language barriers,
and services are not always designed to meet varied cultural needs.

It is worth noting the cultural beliefs of Native Americans regarding old age, which could be a model for the
rest of the population. Tribal elders are respected for their knowledge and experience, and they bear the
responsibility of passing down wisdom to the young. All members of a tribe care for the older adults. Death is
an accepted fact of life, a “changing of worlds” that is not to be approached with fear, for the soul is thought
to be immortal.

Cultural distinctions and differences occur in relationship to how older adults are valued, treated, and
provided care. In some countries, people in older age are admired, honored, and celebrated for their wisdom
and experience. Meanwhile, people living in present- to future-oriented nations often view old adults as less
relevant, burdensome, and owners of the past—espousing outdated ways and traditions.

496

Gender

Women represent the fastest-growing segment of the older population, especially among the oldest-old. Yet
older adult women are at risk for higher levels of poverty and lower Social Security benefits compared with
men. Several factors contribute to this disparity:

Lower lifetime earnings due to job discrimination and interrupted work history due to child rearing and
caregiving for a spouse or other family member (fewer work credits accumulated)
Changes in marital status (divorced, widowed) that tend to leave women in worse shape financially
because their husbands had a higher income than they did
Preexisting economic status (career choice, educational level obtained)
Length of time spent as a widow (women have a higher life expectancy than men)

Because of economic realities, many female heads of household are now supporting three or four generations
within their homes. And the majority of grandparents who are raising grandchildren and serving as caregivers
are women. One reason grandparents may be raising their grandchildren is that their own children are
struggling with addiction.

Gender influences the experience of old age in another way. Women are more likely to experience the death
of a spouse than men are. Widows and widowers experience loneliness and depression that may lead to
unhealthy behaviors. In addition, women are lonelier living with their children without a spouse, while men
are lonelier living alone (Cornwell & Waite, 2009).

497

Sexual Orientation

Older LGBQT individuals are a hidden population that is expected to increase (Cox & Brennan-Ing, 2017).
LGBQT individuals have the same concerns as all older adults do with regard to long-term care, housing,
employment or encore careers, health care, and transportation. LGBQT older adults also serve as caregivers
for parents, siblings, spouses, or partners. But they are also doubly stigmatized, having experienced living in at
least two different cultural networks simultaneously and having had to cope with multiple barriers.

Some older LGBQT individuals hesitate to disclose their sexual orientation at this late stage because they fear
that family members or friends will reject them when they most need support. Also, because the social stigma
of homosexuality and bisexuality is still abundant (even virulent) in many settings, they fear making their
sexual orientation known when seeking senior services and housing. In addition, assisted-living and long-term
care facility policies are established for heterosexual or single residents, so older LGBQT people may have
limited options if they are seeking a gay-friendly long-term care environment. Exhibit 11.8 provides a model
for social work practitioners to better serve the aging LGBQT population.

498

Ability

The numbers of older adults across all levels of physical and mental challenges are growing rapidly, and the
number of people with severe or moderate challenges is expected to more than triple by 2040 (Choi et al.,
2014; Hermans & Evenhuis, 2013). Serious health conditions usually lead to residence in a nursing home
because of the grave hardships of caring for a person with challenges at home. Increasing age is much the
same. According to one survey, at ages 65 and over, only 5% of the population were in nursing homes, but for
ages 85 and over, the figure was 22%. This wide gap is likely to persist indefinitely (Reardon, Nelson, Patel,
Philpot, & Neidecker, 2012).

Exhibit 11.8 R-E-S-P-E-C-T Model for Helping Older LGBQT Clients

Source: Metz (1997).

A huge number of people who reside in nursing homes and are in the severely challenged category are those
with clinically diagnosed Alzheimer’s disease. Alzheimer’s disease affects both physical and mental
functioning. At first, slight memory losses occur, followed by a shuffling gait, stooped posture, and loss of
bowel and bladder control. The symptoms progress at different speeds for each person because, researchers
think, various areas of the brain are affected by the disease process. Despite the sad long-term prognosis for
people with Alzheimer’s, social workers in long-term care settings can optimize the functioning of older adults
by helping them actively exercise their bodies and minds.

499

Intersections of Diversity

The majority (three fourths) of older men but only a minority of older women (one third) are currently
married and living with their spouses—a pattern that is expected to continue over the next several decades.
Older women are twice as likely as older men to live alone (37% and 19%, respectively). The likelihood of
living alone increases with age (Institute on Aging, 2017).

In addition, about 8% of older adults live alone and have no children. The figure for blacks and Asians and
Pacific Islanders is substantially higher (11%) than for whites (8%). There are serious implications for
caregiving as these populations age.

500

Advocacy and Aging

When people refuse assistance or caregiving responsibilities, social workers ethically must intervene to help
family members act, make difficult decisions, let go, or legally prepare for changes in environment or care.
Resources that many older adults require are in the form of nutrition (meals-on-wheels, congregate meals, or
food stamps), long-term care, home health, housing, and respect.

501

Economic and Social Justice

As advocates for social and economic justice, social workers must be a voice for older people approaching or
living in poverty. In the 1970s benefit increases helped boost standards of living for older adults, even though
they also created subsequent concerns about the programs’ sustainability. At the same time that the economic
and political landscapes are causing doubt about how older adults will be able to afford to live, options for self-
support are dwindling as well. The Great Recession hollowed out many retirement accounts, and long-term
care insurance can be crushingly expensive. These are issues that must be addressed for both individuals and
society as a whole, and gerontological social workers could help make a case for the needs of older adults.

Social workers can also advocate for older adults who no longer drive or who have ambulation difficulties
(Berg-Weger, Meuser, & Stowe, 2013; Rusch, Schall, Lee, Dawson, & Rizzo, 2014). Services are available to
help them obtain food, medical care, and other homemaking necessities. However, wait lists of 6 months or
more exist for some older adults who reside in particular states and desire home-delivered meals. As well,
older adults residing in rural areas may have difficulty accessing transportation to medical appointments or
home shopping services to acquire groceries.

With their respect for diversity, social workers are also well trained and positioned to combat ageism. Society
resists embracing the aging population. Battling “old geezer” stereotypes and trying to obtain equal standing
in the workplace continue to be struggles for those age 60 (or even 50) and older. In one survey of 84 people
age 60 and older, nearly 80% of respondents reported experiencing ageism—such as other people’s assuming
they had memory or physical challenges due to their age (Palmore, 2001). The most frequent type of ageism
—reported by 58% of respondents—was being told a joke that pokes fun at older people. Thirty-one percent
reported being ignored or not taken seriously because of their age.

Unfortunately, ageism has seeped into mental health care. Older patients are often viewed by health
professionals as set in their ways and unable to change their behavior. As a result, mental health problems—
such as cognitive or psychological conditions caused at least in part by complex pharmacological treatments—
often go unrecognized and untreated. This deficit in treatment needs to change, because people over the age
of 85, who often depend on medication for an active lifestyle, are the fastest-growing segment of the U.S.
population.

In late May 2017, groups were relieved to learn President Trump’s budget cuts would not directly affect
home-delivered meal programs for low-income older adults. Funding for the Older Americans Act, which
largely funds Meals on Wheels programs in states, seems to have been kept at 2016 levels in Trump’s 2018
budget proposal (Gerstein, 2017).

502

Supportive Environment

Older adults who live in inner-city and suburban areas and those who are homeless, uninsured, or live alone
present with varying risk factors in later life. Suburbanites tend to have nice homes and cars, while inner-city
dwellers reside in cluttered and decrepit projects. Substance use and addiction may be part of the scenery.
Community outreach in the form of distribution of condoms and bleach to clean needles may be required in
some cities where drug dealing and use are rampant (Boeri, Sterk, & Elifson, 2008; Namkee & DiNitto,
2013).

Environmental factors related to caregiving affect both the physical and mental wellness of caregivers. It is
predicted that caregiving will become more complex in part because of the need for long-distance caregiving.
Children and their aging parents often live in different cities, and it may be difficult for the caregivers to take
time from work or family to travel to their parents’ homes. Mental health practitioners must continue to
respond to the concerns of these caregivers and develop options that recognize the precious nature of time.
These same counselors must create ways to use technology effectively to compensate for lacking resources in
environments where the parents reside.

503

Human Needs and Rights

Older adults, like everyone else, have the right to make bad decisions throughout their lives. However, many
who have made bad decisions have reached a point where they have few means—mental, physical, or financial
—of mitigating the consequences. Gerontological social workers cannot change the past, but they can help
find the resources for a safe old age. For example, older adults who have not planned well economically will
require special counseling to help them manage long-term care or aging-in-place needs.

Addiction is another bad choice that gerontological social workers can address. However, social workers must
recognize that older adults rarely use alcohol or drugs to “get high.” Drug or alcohol use that begins after age
60 appears fundamentally different. Typically, people who begin as teenagers or young adults are sensation
seekers with significant rates of psychiatric disorders and antisocial traits. In contrast, older adults tend to turn
to alcohol and drugs to alleviate the physical and psychological pain from the onslaught of medical and
psychiatric illness, the loss of loved ones, or social isolation. The problem is that these psychoactive drugs are
all addicting and can impair cognitive functioning, cause depression, increase the risk of falling, and interact
dangerously with other medications. Moreover, drug and alcohol use in older patients occurs alongside other
medical and psychiatric illnesses. You cannot treat either problem in isolation. There is little doubt that
America faces a looming public substance use and mental health crisis in the aging population. The question
is whether we can meet this daunting challenge with the investment in research and mental health that is
currently allocated. Gerontological social workers can help keep the problem in the public eye (Wu & Blazer,
2011).

Regarding caregiver stress, ethnicity and race, emotional support, and the quality of the current and past
relationship may help mediate caregiver burden. An effective gerontological social worker can help stressed
caregivers improve their relationship with the older adults they care for and also receive the services they need.
Social workers need to point out that caregiving may yield some positive outcomes as well. For example,
through the act of caregiving, individuals can grow in mastery and personal efficacy, and enhance well-being
or self-worth. Caregiving may increase feelings of personal achievement and pride, and enhance meaning and
heighten the sense of closeness and warmth between caregiver and care recipient.

504

Political Access

Ozawa and Yeo (2011) explore how older adults, across their life spans, make decisions for how to spend,
save, or give away money. Depending on one’s cohort, whether part of the Greatest Generation, a baby
boomer, a Gen Xer, or a millennial, Social Security payouts and the eligibility age to receive Social Security
benefits differ (Ozawa & Yeo, 2011). Thus, social workers have a role to play not only in helping older people
maximize their resources and receive aid when needed but also in teaching middle-aged people how to save
money and invest in stocks, bonds, and IRAs (individual retirement accounts). At the same time, social
workers should be advocating for legislation that helps fund resources and programs for older adults now and
in the future.

Aging in place is an ideal for which social workers must advocate. Also, social workers can work to influence
government policies related to public funds for nursing homes and services.

Social workers may expand their clout by partnering with sympathetic lobbyists and national organizations
such as the AARP and the Gray Panthers. Both organizations have long existed to provide support and
services to all older adults. Currently, the AARP has 97 million members and collaborates with more than 93
product companies. The AARP is a powerful lobbying organization with a substantial mailing list of older
adults. Social workers need to have a working knowledge of policies and potential political partners to ensure a
mutually beneficial relationship with organizations such as these.

505

Your Career in Gerontology

Well-respected and accredited colleges and universities across the United States have created degree and
certificate programs for individuals who wish to embrace the challenging and compassionate field of
gerontology. Bachelor’s, master’s, and doctoral degree programs are available that focus on gerontology’s
multidisciplinary approach. Courses can include topics such as theories of aging, ethics, housing, geriatric
psychology, research methods, physiology of aging, social services, government policy, and interesting electives
(e.g., aging and spirituality, aging and the family, women and aging, therapeutic arts, aging and the law,
economics and aging—to name a few). Gerontology minors and graduate certificates in aging studies are also
options for social workers pursuing an MSW degree.

Social workers with gerontology specialties can assess economic well-being, discern political and religious
orientations and promote engagement, link older adults to work (i.e., encore careers), link them to leisure
opportunities (e.g., senior centers, Road Scholar program), connect them to nutrition programs (e.g.,
congregate meals, meals-on-wheels), provide health care and home health social work services, develop
programs and policies, and serve as consultants (e.g., acting as a thought leader for AARP to guide the
organization on how to market products better or collaborate with new resource partners).

Lessons related to gerontology and geriatrics will serve social workers well across practice areas. For example,
social workers in child welfare, family services, mental health agencies, schools, AIDS treatment clinics,
homeless shelters, and Veterans Affairs and naval hospitals may at one time or another be required to assist
older adults and understand the policy issues that affect them. Gerontological or geriatric social workers are
called to help people age resiliently despite the numerous vulnerabilities, inequities, and ageism elders may
experience.

To provide better care for older adults and better support for worn-out caregivers, social workers need to
embrace new interdisciplinary, multidisciplinary, and transdisciplinary integrative models of care that traverse
physical and mental health, long-term care, community-based settings, and social services. And given the
expected increases in the numbers and challenges of older Americans, social workers must endeavor to educate
and recruit more qualified BSW- and MSW-prepared gerontological social workers (Greenfield et al., 2013;
Hooyman, 2006; Hooyman & Kiyak, 2010; Hooyman & Lubben, 2009). More gerontology scholars are also
welcome.

The biggest barrier to attracting social work students to gerontology may be pervasive ageist attitudes. Many
Americans still fear the processes of aging and dying. Younger and healthier people unfortunately tend to
avoid thinking about the issues of mortality and loss of independence, and so they avoid older adults as well. A
comprehensive literature review has noted multiple reasons why social work students hesitate to work with
older adults (Wang & Chonody, 2013):

Limited experience with and exposure to healthy older adults (Reed, Beall, & Baumhover, 1992)
Anxiety related to personal aging (Anderson & Wiscott, 2003)

506

Perception that older adults cannot change (Gellis, Sherman, & Lawrance, 2003)
Perception that older adults are depressed and lonely and have poor hygiene (Mason & Sanders, 2004)
Belief that geriatric social work provides a low salary (Hooyman & Lubben, 2009)
Perception that working with older adults is not challenging or rewarding (John A. Hartford
Foundation, 2009)
Perception that they will have a higher status in the field if they work with children or adolescents (Reed
et al., 1992)

Keep in mind, however, that the number of workers in gerontology and geriatrics is declining precisely when
their services are needed the most. America has certified about half the number of geriatricians it needs, and
few medical students are choosing geriatrics. By 2020 the geriatric nursing workforce is expected to drop by
20%, and geriatric psychiatrists have been decreasing in numbers since 2001. Eldercare is projected to be the
fastest-growing employment sector within the health care industry. The demand for gerontological and
geriatric social workers is growing as well. The U.S. Bureau of Labor Statistics classifies gerontological social
workers as health care social workers and notes how nursing homes and home health care agencies are prime
employers of social workers specializing in gerontology. Without a strong, well-trained cadre of gerontological
social workers, greater demands will be placed on families and caregivers, and of course on older adults
themselves.

Summary

It’s not how old you are, it’s how you are old.

Jules Renard

We all grow older and experience physical changes as we age. We also age in social places and within social relationships and
contexts that have shaped our lives. Humans create their old age as part of life, and societies construct their own views of aging.
Gerontological social workers assess clients by discerning differences between normal and abnormal aging processes within those
contexts. The goal of social work with adults who are older is to help people live well with their aging process and empower societies
to engage with aging along with other aspects of life.

Social workers who decide to work with older adults are and will continue to be in demand. From program and product development
to counseling, and everything in between, diverse jobs are available for social workers who have a passion to serve older generations.
Gerontology is a science and an art; it is the point where education and research meet advocacy and care for the older adult
generation.

507

Top 10 Key Concepts

activities of daily living (ADLs)
ageism
aging in place
Alzheimer’s disease
assisted living
gerontology
nursing homes
Older Americans Act of 1965
Sandwich Generation
senescence

508

Discussion Questions
1. What effect does an aging population have on the U.S. workforce, pension system, and health care services?
2. What biopsychosocial-spiritual challenges do aging Americans face?
3. How well will you manage the four Ds (death, depression, dementia, disability) of aging?
4. How can social workers help bust the myth that older adults are not sexually active?
5. How can ageism be combated?

509

Exercises
1. Why does the United States seem to emphasize youth and deem older adults as lower status?
2. What do gerontological social workers do, and how can they creatively address gaps in service that older adults experience when

they quit working, remain single, become widowed, decide to move or marry late in life, or raise grandchildren?
3. Research workplace issues in social work and management resources: How do generations interact in the workplace? What are

effective strategies for managing and supervising older and younger workers on the job? How do organizations manage the unique
and sometimes competing priorities of multiple generations in the workplace? What are the strengths that older workers and their
younger counterparts bring to the workplace? What are your views on work and older adults? When should people retire?

4. Conduct research to determine how economic and political issues and the status of entitlement programs (e.g., Medicare,
Medicaid, Social Security, long-term care insurance) are affecting the lives of older adults in all parts of our nation.

5. View “Alive Inside” (http://www.aliveinside.us/#alive-inside-theater)—a stirring documentary that follows social worker Dan
Cohen, founder of the nonprofit organization Music & Memory, as he battles amidst a broken health care system to show how
music can enable memory and restore a deep sense of self to people suffering from memory loss.

Online Resources

AARP (www.aarp.org): A nonprofit, nonpartisan membership organization for people age 50 and over, dedicated to
enhancing quality of life for us all as we age; delivers value to members through information, advocacy, and service, and
publishes a monthly bulletin
Alzheimer’s Association (www.alz.org): Formed in 1980 to advance research to end Alzheimer’s and dementia while
enhancing care for those living with the disease
Association for Gerontology in Higher Education (www.aghe.org): Aims to advance gerontology and geriatrics education in
academic institutions, and to provide leadership in and support of the provision of gerontology and geriatrics education to
faculty and students at educational institutions
Centers for Medicare and Medicaid Services (cms.hhs.gov): Administers the Medicare and Medicaid programs and the State
Children’s Health Insurance Program, which provide coverage for close to 1 out of 4 Americans
Facts on Aging Quiz (cas.umkc.edu/gerontology/agingfactsquiz.asp): Lists questions that can lead to a lively discussion on
aging
Gerontological Society of America (www.geron.org): The nation’s oldest and largest interdisciplinary organization devoted
to research, education, and practice in the field of aging, with the principal mission of advancing the study of aging and
disseminating information among scientists, decision makers, and the general public
“Human Values in Aging” e-newsletter (subscribe via [email protected]): Publishes items on positive aging,
including spirituality, autobiography, lifelong learning, and late-life creativity
National Center for Gerontological Social Work Education (www.cswe.org/CentersInitiatives/GeroEdCenter.aspx):
Provides resources for social work faculty, students, and practitioners who are committed to enhancing gerontological
competence
National Institute on Aging (www.nih.gov/nia): One of the 27 institutes and centers of the National Institutes of Health;
leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life, and is the
primary federal agency supporting and conducting Alzheimer’s disease research
Profile of Older Americans (https://aoa.acl.gov/Aging_Statistics/Profile/index.aspx): Annual statistical profile, compiled by
the U.S. Administration on Aging, that is a gold mine for data and trends
Caregiving (http://www.prb.org/Publications/Articles/2016/todays-research-aging-caregiving.aspx): Section “Family
Caregiving for Older People” provides resources for caregivers
Next Avenue (http://www.nextavenue.org/the-encore-career-movement-grows-up): Provides another view about what
retirement could mean via encore careers

Student Study Site

510

Sharpen your skills with SAGE edge at edge.sagepub.com/cox2e

SAGE edge for Students provides a personalized approach to help you accomplish your coursework goals in an easy-to-use learning
environment.

511

Chapter 12: Criminal Justice

Source: The Washington Post/Contributor/Getty Images

512

Learning Objectives
After reading this chapter, you should be able to

1. Identify and describe important concepts and terms in the criminal justice system.
2. Analyze the contextual nature of criminal behavior, as politically defined and relative to time and place.
3. Identify and describe the intended functions of punishment and imprisonment in the United States.
4. Describe and explain the differences and tension between social work and criminal justice perspectives concerning criminal

behavior.
5. List and explain areas to advocate for change and reform in the criminal justice system.
6. Describe and analyze how specific population groups are advantaged and disadvantaged in the criminal justice system.
7. Describe the importance of empowerment of victims and criminals in advocating for fair and just legal processes and systems.

Michelle Combats Racial and Ethnic Imbalances in the Juvenile Justice System

As a BSW-level social worker employed at an urban juvenile probation agency, Michelle interacts with multiple teenagers and
encounters a wide range of situations involving criminal acts. Michelle’s clients have experienced numerous forms of trauma, such as
physical and sexual abuse, and have been diagnosed with various mental health and substance problems. Michelle works mainly with
juveniles and probation officers to conduct assessments and coordinate referrals to mental health, family, and substance services.

Michelle has learned a great deal about exposure to trauma, dysfunctional family dynamics, and legal systems from her day-to-day
contact and discussions with her clients and their families. She has learned as well from attorneys, police officers, social workers,
judges, and administrative staff at her agency.

As a social worker practicing in a criminal justice setting, Michelle is mindful of her responsibility to identify and address larger-
scale, structural issues affecting her clients. Glaringly, 55% of her clients are members of a racial minority group, largely African
American, even though only 30% of the juvenile population in her urban area comprises members of a racial minority group. The
disproportionate involvement of minorities in the juvenile criminal justice system is a problem in Michelle’s city as well as in many
areas across the nation. She has heard that Washington State has been successful in documenting the racial and ethnic imbalance in
its juvenile justice system and has passed laws to monitor and reduce this imbalance in its legal systems (Hsia, Bridges, & McHale,
2004). Helping professionals and leaders in Michelle’s state’s juvenile justice system would benefit from additional information and
better data to understand why youth from ethnic and racial minorities appear to become disproportionately involved in the juvenile
justice system and how they might help combat the imbalance.

The profession of social work has experienced a lengthy and at times tension-filled relationship with the field
of criminal justice. Although the criminal justice system is an important arena for employment for social
workers and includes therapeutic and rehabilitative services, the historical roots of criminal justice in the
United States have focused on law enforcement, incarceration, and the punishment of criminal behavior.
Traditionally, professionals in criminal justice have approached crime and delinquency as a matter of personal
responsibility and thus have tended to work in law enforcement and judicial and correctional settings with a
heavy emphasis on individual accountability. Although social workers share the view that people involved in
the criminal justice system have responsibility for their actions, criminals are also seen as a product of their
biopsychosocial environment.

Time to Think 12.1

What are some distinct advantages and privileges that Caucasian and affluent people have in minimizing contact with the court
system? How might parents and family members use their status to influence and intervene when their young people become
involved with it? Consider the importance of legal representation.

513

Social workers respect criminals for their inherent worth as individuals and often represent people in need of
help, especially with mental health and substance use issues. In practice, social workers have influenced
criminal justice interventions by advocating for entities such as drug and mental health courts, where judges
can explicitly consider, order, and support therapy and intervention plans for criminals as an alternative to
punishment.

Differing perspectives about the nature of criminal behavior can create tension in the relationship between
social workers and criminal justice professionals. It is too simplistic but also true to a degree to say that law
enforcement professionals, correction officers, and court officials often view social workers as being too
understanding, caring, and compassionate. Social workers struggle to accept what they often think of as rigid,
dehumanizing, and punitive practices in legal and correction systems. Exhibit 12.1 highlights some of the
tensions between social workers and juvenile justice personnel (e.g., probation officers, court officials, law
enforcement officers) and the social work perspective on those tensions (Peters, 2011).

514

Central Concepts in Criminal Justice and Crime

Crime in the United States is a long-standing and significant social problem that has resulted in the creation
of myriad federal, state, and local organizations, and a complex labor force charged to process and respond to
criminal activity. The criminal justice system refers to a large network of organizations (e.g., courts, police
departments, prisons, jails, probation agencies) dedicated to the enforcement of laws and the administration of
justice.

Crime refers to acts or behaviors that are prohibited by criminal law and punishable by negative sanctions
(e.g., probation, fine, jail term). Laws are legislative acts passed at the local, state, and federal levels by
corresponding political entities (e.g., city councils, state legislators, the U.S. Congress) to define and regulate
acceptable and unacceptable behavior. Although debatable, the presumption in the United States is that
people, even after being charged with a violation of law, are innocent until proven guilty. But if they are found
guilty of having committed a crime, they are classified as criminals.

515

Types of Crimes

Crimes are typically classified into two general categories:

Misdemeanor crimes are relatively minor crimes (e.g., traffic violations, public drunkenness, shoplifting)
and are punishable by a fine and a small amount of time (e.g., less than 1 year) in jail.
Felonies are serious crimes (e.g., murder, rape, aggravated assault) and are punishable by extended
imprisonment and sometimes death.

It is important to note that both types of crime are recorded and become part of a person’s legal record. A
criminal record is ordinarily a public document. It creates a stigma for the person. One’s criminal record is
frequently reviewed in relationship to applications for employment, apartment rental, and insurance, and in
the event of any subsequent criminal behavior. If you enter a professional major, do not be surprised if your
field agency, licensing board, or future employer requires a criminal background check prior to field
placement, licensure, or employment.

Exhibit 12.1 Tensions Between Social Workers and Juvenile Justice Personnel

Source: Peters (2011, pp. 357–363).

Crime is classified in several other ways:

Violent crimes are typically crimes against other people that involve the use of force or threatened force.
Examples of violent crimes include robbery (stealing from another person), aggravated assault
(attacking another person physically), rape (sexual penetration through the use of force), and homicide
(illegally causing the death of another person).
Property crimes involve the taking of money or property from others without force or destruction.
Examples of property crimes include arson (malicious burning of property), motor vehicle theft, larceny
(stealing of property), and burglary (breaking into a house or building to steal).
Victimless crimes involve illegal acts that (arguably) do not have a readily identifiable victim. Examples
include prostitution, illegal gambling, and the selling of drugs. Many social workers would suggest that
family members and loved ones are victims of this type of crime.
Hate crimes involve intimidation and the intent to hurt people based on race, ethnicity, national origin,

516

religion, sexual orientation, disability, and other forms of diversity. Hate crimes include the use of verbal
threats, acts of violence, fear, physical attack, and explosives.
White-collar crime involves acts (e.g., fraud, theft, falsification of records) that occur in the course of
employment or normal work activities. Corporate criminals commit crimes on behalf of a corporation
and with its support.

The primary source for crime information in the United States is the Uniform Crime Report, an annual
publication of the Federal Bureau of Investigation (FBI). The accuracy of information from this report is
always a concern, as data reflects the number of crimes reported, not the number actually committed.

Nevertheless, the preliminary 2011 report indicates that violent crimes and property crimes in the United
States are down 4% and 0.8%, respectively, from 2010 figures (Federal Bureau of Investigation, 2012). These
declines continue a yearly trend (since 2006–2007) in which U.S. crime rates have fallen in nearly every
category. Despite a common misperception advanced by the sensationalizing of crime in modern media,
television crime series, computer games, and movies, crime rates in the United States have been falling in
recent years, as illustrated in Exhibit 12.2.

517

The Contextual Nature of Crime

In the United States, laws that have been passed are modified or amended on a regular basis. In addition,
although some laws apply across states, they are political acts passed by legislative bodies in a particular time
and place. As a consequence, a behavior legislated as illegal at one point in time and within a specific
jurisdiction may in a different locale or during a different time be deemed legal.

To exemplify the contextual nature of laws and criminal behavior, consider Prohibition. During the
Prohibition Era in the United States (1920–1933), it was illegal to sell, manufacture, and transport alcohol.
Defying these laws, “bootleggers” manufactured alcohol in homemade stills and set out in “souped-up” cars
that could outrun police to transport and distribute their contraband to alcohol users and distributors in
nearby counties. When the prohibition laws were repealed, however, alcohol became legal in the United
States, and it has since become a multibillion-dollar industry. The legacy of bootleggers lives on in the
organized racing of “stock cars”—similar to the souped-up cars of the Prohibition Era—overseen by the
National Association for Stock Car Auto Racing (NASCAR). In fact, some of the early NASCAR drivers
had been bootleggers. Today, alcohol is readily sold at many sporting events, including the popular NASCAR
races. Several alcohol manufacturers prominently advertise their products through car sponsorship in
NASCAR. Despite this dramatic turnaround, people who were convicted of the sale, manufacture, and/or
transportation of alcohol during the Prohibition Era would continue to be classified as criminals.

NASCAR cars often sport ads for alcoholic products. This is reflective of NASCAR’s history, since some of
the first NASCAR drivers were bootleggers.

Source: Jerry Markland / Stringer / Getty Images

The contextual nature of crime is also demonstrated in the label of “criminal” or “juvenile delinquent.” This
label is formally bestowed after a person is caught, charged, and deemed guilty of committing a crime.
However, decisions by police officers, prosecutors, magistrates, and juries impact whether a person is charged,
prosecuted, and ultimately found guilty of violating a law. Some people charged with a crime avoid being
found guilty of criminal acts, whether through legal counsel, persuasive argument, or other forms of influence.
Those with power, resources, and clout may be able to avoid the label of criminal, but people unable of
mounting meaningful defenses often cannot avoid it. Affluent community members possess resources and hire
attorneys to enable maneuvering around and through the criminal justice system to have cases dropped or
reduced to a lower charge. Additionally, at times, people who have been found guilty of crime can petition to
seal their records from public view.

518

519

The Correctional System

Once a person has been convicted of a crime, and if the crime is serious enough and the judge deems fitting,
the person enters the correctional system. There are three particularly important aspects of corrections:

Probation constitutes a sentence given to an offender by a judge, typically in lieu of prison, carrying
specific requirements and conditions, such as regular reporting, counseling, drug testing, and substance
treatment. A person on probation is monitored by a probation officer. If an offender violates the terms
of probation, a warrant for arrest can be issued and the offender may serve time in prison.
Parole is the early release of an inmate from prison, supervised by a parole officer. Much like probation,
parole specifies conditions for offenders. If parole requirements are violated, the offender can be sent
back to prison.
Prison is frequently viewed by judges as the most expensive and last-resort correctional option for
offenders. Prison is a broad term that encompasses being held in local and county jails as well as state
and federal prisons. In many jurisdictions, prisons are full and the cost of incarceration, being placed in
prison, is prohibitive. For 2011, it was estimated that the average cost of incarceration for federal
inmates was $28,893.40 per year and $26,163 per year for an inmate in a community corrections center
(Prisons Bureau, 2013).

520

Juvenile Justice and Corrections

Juvenile justice and corrections deserves special recognition because juveniles, who are people under the age of
18, are typically viewed and treated differently from adults in the criminal justice system. The UN Convention
on the Rights of the Child defines a child as any human being under the age of 18; however, in many states,
youth can be tried as adults in an adult criminal court. Some states (e.g., Connecticut, New York, and North
Carolina) automatically prosecute 16- and 17-year-olds as adults. Other states allow judges the discretion to
have youth tried in adult criminal courts. An emancipated adult is a juvenile who has been granted the status
of adulthood, usually by court order. These types of legal distinctions add to the confusion of who is
considered a juvenile and who an adult.

Juveniles are deemed to be under the supervision and control of parents or guardians, who bear oversight and
some responsibility for the minor’s behavior. However, especially with adolescents, parental control of
children becomes a challenge and often problematic.

Crimes committed by juveniles typically involve sexual or antisocial “acting out” (impulsively and
uncontrollably behaving in a forbidden way, usually to get attention), truancy, running away, illegal use of
drugs (including alcohol), shoplifting, property damage, fighting, and gang behavior. Juveniles are uniquely
prone to status offenses that would not be classified as crime if committed by an adult. Examples of status
offenses include underage drinking and violation of curfews. Appropriately, a juvenile who becomes involved
in the criminal justice system is often brought to helping professionals (including social workers), agencies,
and for help. Many times, the criminal actions of the juvenile involve and reflect interpersonal and family
conflicts and dysfunctions.

Dependent upon the offense and circumstances surrounding a juvenile’s crime, judicial decisions against
juveniles involve multiple options (e.g., probation, fines, curfews, and incarceration). Diversion programs are
also options, where offenders participate in rehabilitation programming aimed at addressing behaviors and
problems that contributed to an arrest. A common goal of diversion programs involves prevention of
subsequent criminal behavior. Diversion programs can provide an opportunity for a juvenile to avoid a
criminal record.

Juvenile corrections refers to intervention, services, and programs for minors as a result of their involvement
in the criminal justice system and courts. Juvenile corrections can include the use of locked juvenile detention
facilities.

Time to Think 12.2

How do public opinion and policy differ for criminal behavior by juveniles versus adults? Does the age of the juvenile or child make a
difference, or are the type of crime and circumstances surrounding the act more important? As you read this chapter, ask yourself
how juveniles and adults are viewed and treated differently by police, courts, judges, and other elements of the criminal justice
system.

521

522

Conflicting Attitudes about those Who Commit Crimes

In the United States there are two dominant underlying values with regard to dealing with criminals: the need
for transgressors to take individual responsibility, and the need for society to punish transgressions. These
perspectives are so pervasive among voters that many politicians include “anticrime” and “hard-on-criminals”
messages in their election campaigns. Of course, it is difficult to imagine a politician being in favor of crime.
Politicians seldom speak kindly of criminals either (except perhaps powerful white-collar or corporate
criminals), but their disdain for criminals overlooks the fact that many people who become involved in the
criminal justice system have experienced mental and emotional challenges and addictions. Additionally, many
criminals have been victims of trauma, abuse, and exploitation.

This is not to say that criminals should not be held accountable for their actions. Instead, it behooves us all to
treat criminals in a just fashion and, upon their release, to allow them to move forward in their lives as
productive members of society. Interestingly, many Americans seem to be single-minded about crime, tending
to see the purpose of incarceration as either punishment or rehabilitation.

523

Attitudes Toward Punishment

The system for the punishment and imprisonment of criminals in the United States is designed to fulfill four
functions (Kendall, 2013), although its success in fulfilling them is uneven:

Social protection: It is true that criminals who are in jail will no longer be able to commit crimes; so the
public is protected. However, many times society is protected only temporarily, until the criminal is
released from jail.
Deterrence: It is thought that fear of punishment will prevent future criminal activity. It is not clear,
however, that punishment does have a deterrent effect. Criminologists have noted that many crimes are
committed in the heat of the moment, with little consideration of the consequences, and 30% to 50% of
those who are released from prison commit additional crimes. In addition, much of the criminal justice
system is predicated on a reactive approach, taking action only after a crime has occurred.
Rehabilitation: Providing services and programs to offenders while they are incarcerated is supposed to
facilitate their successful, law-abiding reentry into the community. Unfortunately, rehabilitation
programs are few in number, understaffed, and underfunded.
Retribution: The belief that penalty or punishment should match the severity of the crime to provide
“payback” is popular. For example, by this thinking, people who commit homicide should be punished
more severely than people who commit fraud.

Currently, criminal punishment in the United States tends toward the retributive end of the spectrum.
Presently the United States incarcerates more of its citizens than any other nation in the world. Indeed there
are appropriately 2.2 million people incarcerated, which has led to unprecedented prison overcrowding and
increasing strain on state budgets. People joke about the indignities of being incarcerated and react negatively
to appeals for funding for more humane conditions, believing that criminals are getting “what they deserve.”
Thus, jails and prisons in the United States are overcrowded, forcing prisoners into cells designed for far fewer
inhabitants. Many states have turned to private prisons as a means to control costs. But this outsourcing
approach is often a cost-cutting measure and tends to reduce appropriate oversight concerning the humane
treatment of prisoners and the impact of prisoners’ living in close quarters with one another.

Yet, at the same time, crime and criminals are often glamorized. Popular television shows such as “Breaking
Bad,” “The Good Wife,” and “Blue Bloods” provide a misleading and glorified depiction of crime, law
enforcement, and the legal system. National and local news programs exploit criminal activity as a mechanism
to boost ratings and capture the attention of viewers. What the general public views has little relationship to
the everyday workings and proceedings of law enforcement, criminal justice, and correctional systems.

Exhibit 12.2 Changes in Crime Rates by Type of Crime, 1992–2011

524

1Populations are U.S. Census Bureau provisional estimates as of July 1 for each year except 2000 and
2010, which are decennial census counts.

2The murder and nonnegligent homicides that occurred as a result of the events of September 11, 2001,
are not included in this table.

3The crime figures have been adjusted.

Note: Although arson data is included in the trend and clearance tables, sufficient data is not available to
estimate totals for this offense. Therefore, no arson data is published in this table.

Percentage Change in Volume and Rate per 100,000 Inhabitants for 2 Years, 5 Years, and 10
Years

Percentage Change in Volume and Rate per 100,000 Inhabitants for 2 Years, 5 Years, and 10

Years
Violent
Crime

Violent
Crime
Rate

Murder And
Nonnegligent
Manslaughter

Murder And
Nonnegligent
Manslaughter
Rate

Forcible
Rape

Forcible
Rape
Rate

Robbery
Robbery
Rate

2011/2010 –3.8 –4.5 –0.7 –1.5 –2.5 –3.2 –4.0 –4.7

2011/2007 –15.4 –18.1 –4.7 –17.4 –9.5 –12.4 –20.8 –23.3

2011/2002 –15.5 –21.9 –10.0 –16.8 –12.4 –19.0 –15.8 –22.2
Source: Federal Bureau of Investigation (2011).

Television shows, such as Breaking Bad, can glorify crime.

525

Source: AF archive / Alamy Stock Photo

Social Work in Action

526

Dr. Tina Maschi and Diverting Delinquent Youth
Dr. Maschi is a social worker, researcher, and university professor. She has conducted research and published widely in the area of
criminal justice and juvenile delinquency. In one of her many publications, Dr. Maschi points out “the need to create more
opportunities to divert delinquent youths into community-based interventions to prevent or delay institutional placements”
(Schwalbe, Hatcher, & Maschi, 2009, p. 31). The general premise is that when problems for youth arise, early use of counseling and
intervention services holds promise for preventing or minimizing involvement with the juvenile justice system.

Social workers practicing in community-based youth treatment centers and child welfare agencies play an important professional role
in intervening with youth who are exhibiting problems with school, drugs, inappropriate behavior, and their family. When
counseling and interventions are effective, the quality of life for a juvenile becomes enhanced and her or his life course can move
away from crime and exposure to juvenile and adult justice systems.

One of the more rewarding aspects in the life of a social worker is helping people change their lives. Practice with troubled youth can be both
challenging and rewarding and often involves a family system. Do you have an interest and temperament for providing services to youth,
many of whom are at a pivotal time in their biopsychosocial development and face challenging parental influences?

Working with youth and juveniles requires both compassion and the ability to hold youth and parents responsible for their actions. Are these
types of professional expectations in your comfort zone?

527

Attitudes Toward Rehabilitation

Another place where American values conflict with reality is in the professed desire to have criminals “pay
their dues,” become rehabilitated while in the system, and then return to society as productive citizens. In fact,
many helping professionals are concerned about the lasting negative effects of being found guilty of
committing crimes. Being labeled as a criminal can present significant challenges for obtaining employment,
housing, and credit, as well as damaging one’s self-image and self-esteem. Recidivism, the tendency for
former inmates to return to prison, is common because people who have been labeled as criminals find it so
difficult to reintegrate into society. Exhibit 12.3 lists some facts about recidivism in the United States.

In fact, it is common for people who are incarcerated to become even more expert at crime at the same time as
they are becoming less employable. People have a greater tendency to participate in criminal activities and
deviance when they frequently associate with criminals and those deemed to be deviants (Sutherland, 1939).
Thus, overcrowded prisons can be viewed as educational grounds for future criminal behavior.

528

Social Workers and the Criminal Justice System

People working in the criminal justice system focus on the law’s definitions of what is acceptable or
unacceptable and enforce those laws through arrest of people accused of crime, through prosecution, and
through sentencing. In contrast, social work intervention requires a thorough understanding of client behavior
and contextual factors influencing criminal acts, such as upbringing, family, friends, subculture, and
community. Social work is thus more than affirming and reinforcing social norms through the enforcement of
laws. People do not live in isolation but are social beings who long for social support and want to know they
matter. To be an effective social worker requires the ability to influence criminal behaviors and confront social
conditions that give rise to and support criminal action.

Exhibit 12.3 Recidivism of Prisoners in 30 States, 2005–2010

Source: Durose, Cooper, and Snyder (2014, p. 1).

529

Forensic Social Work

Much of what social workers do within the criminal justice system can be called forensic social work. Forensic
social work applies a social work outlook to legal issues and systems and litigation. These are some of the tasks
forensic social workers perform:

evaluating criminal and civil competency, court-ordered psychotherapy, evaluation of suitability to
parent, child and adult custody evaluation, mediation services, probation and parole services,
consultant to attorneys, termination of parental rights evaluations, bonding and attachment
assessments, correctional services, domestic violence services, international child abduction, . . .
protective shelters, [and] rebuttal witnesses. (Munson, 2011, pp. 39–40)

The National Organization of Forensic Social Work was established to advance education in the field of
forensic social work. It supports annual conferences, political action, a professional literature newsletter and
journal, and networking opportunities. Social workers and their clients benefit from specialized education and
training opportunities provided by organizations such as this one.

As an area of practice, forensic social work requires social workers to learn and share specific ways to promote
effective social work practice and human rights in areas such as racial and ethnic imbalances in the criminal
justice system, dehumanizing aspects of and conditions in prisons, mental health and addiction services, and
living conditions that place people at risk of committing crimes (Maschi & Killian, 2011, pp. 30–31). The
Journal of Forensic Social Work provides social workers with valuable and contemporary perspectives and
research on a variety of forensic topics for use in practice.

530

Social Work Values Regarding Criminal Justice

If you are interested in social work and criminal justice, it is important to understand the need to hold people
who have committed crimes responsible for their actions. But at the same time, it is also important to have
compassion for those who may feel disempowered and are caught up in the system. The following values are
key to contemporary social work practice:

Prevention: This should be the first goal. Lawbreakers are often between the ages of 15 and 25. Social
workers should be concerned with designing, implementing, and funding programs and services that
will keep children and young adults away from antisocial activities and out of the criminal justice system.
Prevention of crime reduces the number of victims and is more humane than letting crime occur and
then punishing offenders.
Justice: Members of certain population groups (especially those of particular races, ethnicities, and social
classes) have distinct advantages and disadvantages in the criminal justice system. Advocating for fair
and equitable access to information, services, and resources across population groups is crucial to
promote social justice.
Dignity: In addition to being treated fairly, people accused and found guilty of crimes, as well as their
victims, deserve to be treated respectfully and humanely. It is important to recognize and consider their
challenges, which may include mental health, addiction, and trauma of victimizations.
Best practices and quality services: Offenders and victims of crime should have access to appropriate and
effective legal representation, mental health programs, and addiction services. Social workers in the
criminal justice system provide many of these services and must focus on the dignity and needs of each
person, whether offender or victim. In addition, effective social workers advocate at the local, state, and
federal levels for access to competent professionals implementing best practices in their respective
disciplines.
Restorative justice: Crime is viewed as a violation of relationships between people. Emphasizing the
human nature of crime, it is important for offenders to acknowledge guilt and harm to others, sincerely
apologize for their actions, and seek any appropriate restitution to those hurt. Diversion programs many
times include restorative justice elements in program delivery.

Forensic social workers examine issues such as disproportionate minority contact in the criminal justice
system, and work to affect change in these areas.

Source: ©iStockphoto.com/grahambedingfield

531

532

Interactions With the Criminal Justice System

The criminal justice system and its multiple components and players constitute a complex structure of officials
and programs in the United States. At times, attorneys are needed and hired simply to help clients navigate
the system. To be effective practitioners, social workers must also become familiar with the people, places,
processes, and organizations within their local and relevant criminal justice systems.

Police

There are many different types of police officers, individuals sworn and authorized by local, state, county, or
federal authorities to enforce and uphold laws. Police in its most general use includes city and township officers
as well as county sheriffs, state highway patrol officers, and federal enforcement agents—FBI agents; agents of
the Bureau of Alcohol, Tobacco, Firearms and Explosives; and so forth. Police officers are usually called on to
be the first responders to criminal activities.

Social workers often work closely with police officers, especially in relationship to specific problems (e.g., child
neglect and abuse investigation) and population groups (e.g., victims of domestic violence). In some
jurisdictions, police officers and social workers share their expertise as members of uniquely designed and
trained teams to investigate certain incidences of rape, child abuse, and domestic violence. Additionally, when
social work intervention is mandated by court order, police officers may be called on to enforce the relevant
aspects (e.g., placement of a child) of the court order.

Courts

Courts determine whether people accused of committing crimes are gui